Section 940.160   Plan of Correction

a)         If the Department finds that a health facility is in violation of the Act, the health facility may submit to the Department, for its approval, a plan of correction.  (Section 17 of the Act)

b)         In determining whether to approve the plan of correction, the Department shall consider the following:

1)         Whether the plan of correction ensures access to health care information and services for limited-English-speaking or non-English-speaking residents or patients and deaf residents or patients;

2)         Whether the plan of correction addresses the conditions or occurrences that are the basis of the violation;

3)         Whether the plan of correction is specific enough to indicate corrective actions the facility will be taking or has already taken to abate, eliminate or correct the violation;

4)         Whether the plan of correction provides steps to avoid the violation or to prevent similar violations from recurring, including an evaluation and revision, as necessary, of policies and procedures, and staff training; and

5)         Whether the corrective action will be completed in a reasonable time frame, considering the seriousness of the violation, any possible harm to residents or patients, and the extent and complexity of the corrective action.

c)         The Department shall notify the health facility of the approval or disapproval of the plan of correction.  A notice of approval shall include the date on which the plan of correction was submitted, for the purpose of establishing the 6 month time period required in subsection (d) and in Section 17 of the Act.

d)         If a health facility violates an approved plan of correction within 6 months after its submission, the Department may impose a penalty on the health facility.  (Section 17 of the Act)  The Department’s decision to impose a penalty shall be based on:

1)         The severity of harm, including death or serious physical or mental harm, that has resulted to a resident or patient and the extent to which residents or patients have been subject to potential serious harm. 

2)         The gravity of the violation and the extent to which the provisions of the Act or this Part were violated, including whether the violation recurred or continued, is widespread throughout the facility or evidences a flagrant violation of the Act or this Part. 

3)         The extent and seriousness of any previous violations committed by the facility and the extent of diligence exercised by the facility to correct such violations, including evidence that the violations constitute a pattern of deliberate action by the facility.  The effect of any change in the ownership and management of the facility will be considered in relation to the seriousness of previous violations.

4)         Any possible financial benefit to the facility as a result of committing or continuing the violation.  Such benefits include, but are not limited to, avoidance of costs associated with staff salaries, consultant fees, or direct patient care services.