Section 390.278  Plans of Correction

a)         The situation, condition or practice constituting a Type "AA" violation or a Type "A" violation shall be abated or eliminated immediately unless a fixed period of time, not exceeding 15 days, as determined by the Department and specified in the notice of violation, is required for correction. (Section 3-303(a) of the Act)

b)         The facility shall have 10 days after receipt of notice of violation for a Type "B" violation, or after receipt of a notice under Section 390.277(e) of failure to correct a situation, condition, or practice that resulted in the issuance of an administrative warning, to prepare and submit a plan of correction to the Department.  (Section 3-303(b) of the Act)

c)         Within the 10-day period, a facility may request additional time for submission of the plan of correction.  The Department will extend the period for submission of the plan of correction for an additional 30 days, when it finds that corrective action by a facility to abate or eliminate the violation will require substantial capital improvement.  The Department will consider the extension and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the residents of the facility in determining whether to grant a requested extension.  (Section 3-303(b) of the Act)

d)         No person shall intentionally fail to correct, or interfere with the correction of, a Type "AA", Type "A", or Type "B" violation within the time specified on the notice or approved plan of correction under the Act as the maximum period given for correction, unless an extension is granted pursuant to subsection (c) and the corrections are made before expiration of extension. A violation of this subsection (d) is a business offense, punishable by a fine not to exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103 of the Act and Section 390.120(c) as to submission of false or misleading information in a license application.  (Section 3-318(a)(1) and (b) of the Act)

e)         Each plan or correction shall be based on an assessment by the facility of the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.  The facility shall maintain evidence of the assessment and evaluation.  Each plan of correction shall include:

1)         A description of the specific corrective action the facility is taking, or plans to take, to abate, eliminate, or correct the violation cited in the notice;

2)         A description of the steps that will be taken to avoid future occurrences of the same and similar violations; and

3)         A specific date by which the corrective action will be completed.

f)         Submission of a plan of correction shall not be considered an admission by the facility that the violation has occurred.

g)         The Department will review each plan of correction to ensure that it provides for the abatement, elimination, or correction of the violation. The Department will reject a submitted plan only if it finds any of the following deficiencies:

1)         The plan does not appear to address the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences;

2)         The plan is not specific enough to indicate the actual actions the facility will be taking to abate, eliminate, or correct the violation;

3)         The plan does not provide for measures that will abate, eliminate, or correct the violation;

4)         The plan does not provide steps that will avoid future occurrences of the same and similar violations; or

5)         The plan does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the residents, and the extent and complexity of the corrective action.

h)         When the Department rejects a submitted plan of correction, it will notify the facility.  The notice of rejection shall be in writing and shall specify the reason for the rejection.  The facility shall have 10 days after receipt of the notice of rejection in which to submit a modified plan. (Section 3-303(b) of the Act)

i)          If a facility fails to submit a plan or modified plan meeting the criteria in subsection (e) within the prescribed time periods in subsection (b) or (c), or anytime the Department issues a Type "AA", a Type "A", or repeat Type "B" violation, the Department will impose an approved plan of correction.

j)          The Department will verify the completion of the corrective action required by the plan of correction within the specified time period during subsequent investigations, surveys and evaluations of the facility.

(Source:  Amended at 46 Ill. Reg. 8192, effective May 6, 2022)