Section 264.1450  Notice of Violation and Plan of Correction

a)         The Department will determine whether a birth center is in violation of this Section no later than 60 days after completion of each special inspection, survey, evaluation, or plan of correction. (Section 55(e) of the Act)

b)         Upon determination that the licensee or applicant is in violation of the Act or this Part, the Department shall issue a written Notice of Violation and request a plan of correction.  The notice shall specify the violations in a Statement of Deficiencies and instruct the licensee or applicant to submit a plan of correction to the Department’s central office.  A birth center has 10 days after the date of service of the Notice of Violation to submit a plan of correction. 

c)         Within the 10-day period, a licensee or applicant may request additional time for submission of the plan of correction.  The Department may extend the period for submission of the plan of correction for up to an additional 30 days if the Department finds that corrective action by the birth center to abate or eliminate the violations will require substantial capital improvement.  The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the clients of the birth center in determining whether to grant a requested extension.

d)         Each plan of correction shall be based on the birth center's assessment of the conditions or occurrences that are the basis of the violations and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.  The birth center shall maintain documentation of such assessment and evaluation.  The plan of correction may contain related comments or documentation provided by the birth center that may refute findings in the report, explain extenuating circumstances that the birth center could not reasonably have prevented, or indicate methods and timetables for correction of deficiencies described in the report.  (Section 55(d) of the Act)  Each acceptable plan of correction shall include:

1)         The procedure for correcting each deficiency cited, typed in the right-hand column of the original Statement of Deficiencies, including the following:

A)        specific actions that the birth center will be taking to abate, eliminate, or correct the violation, and

B)        steps that will avoid future occurrence of the same and similar violations.

2)         The title of the individual responsible for implementing and monitoring the plan of correction;

3)         Documentation that the birth center has incorporated systemic improvement efforts into its quality assessment and performance improvement program to prevent the recurrence of the deficient practice;

4)         Supporting documentation of correction;

5)         Procedures for monitoring and tracking to ensure that the plan of correction is effective;

6)         A completion date for correction of each deficiency cited, along with interim dates for any phases or intermediate steps; and

7)         Date and signature of the authorized representative, on the bottom of page one of the original Statement of Deficiencies and plan of correction.

e)         Submission of a plan of correction will not be considered an admission by the birth center that the violation has occurred.

f)         The applicant or licensee may submit additional information in response to the Notice of Violation that it believes will clarify the condition or alleged violation.  The Department will consider the information in reviewing the applicant's or licensee's response and the plan of correction.

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 if it fails to address any of the requirements in subsection (d).

h)         The Department will notify the licensee or applicant if the plan of correction is rejected, including specific reasons for the rejection of the plan.  The birth center shall submit a modified plan that addresses the requirements of subsection (d) of this Section within three days after receipt of the notice of rejection.

i)          If a licensee or applicant fails to submit a modified plan of correction as required in subsection (h), or if the modified plan is not acceptable to the Department, the Department will specify and impose a plan of correction.

j)          The Department shall maintain all special inspection, survey, or evaluation reports for at least 5 years in a manner accessible to the public. (Section 55(f) of the Act)