Current through Register No. 40, October 3, 2024
(a) The department
shall impose administrative remedies for violations of He-A 304, including:
(1) Requiring a certificate holder to submit
a POC; and
(2) Imposing a directed
POC upon a certificate holder.
(b) When administrative remedies are imposed,
the department shall provide a written notice, as applicable, which:
(1) Identifies each deficiency; and
(2) Identifies the specific remedy(s) that
has been proposed.
(c) A
POC shall be developed and enforced in the following manner:
(1) Upon receipt of a notice of deficiencies,
the certificate holder shall submit a written POC for each item on the notice
describing:
a. How the certificate holder
intends to correct each deficiency;
b. What measures will be put in place, or
what system changes will be made to ensure that the deficiency does not
recur;
c. The date by which each
deficiency shall be corrected; and
d. The position of the employee responsible
for the corrective action;
(2) The certificate holder shall submit a
written POC to the department within 21 days of the date on the letter that
transmitted the notice of deficiencies unless the certificate holder requests,
either verbally or in writing, and the department agrees, to extend that
deadline, based on the following criteria:
a.
The certificate holder demonstrates that he or she has made a good faith effort
to develop and submit the POC within the 21 calendar day period but has been
unable to do so; and
b. The
department determines that the health, safety, or well-being of clients will
not be jeopardized as a result of granting the extension;
(3) The department shall review each POC and
accept each plan that:
a. Achieves compliance
with He-A 304;
b. Addresses all
deficiencies as cited in the notice of deficiencies;
c. Prevents a new violation of He-A 304 as a
result of implementation of the POC; and
d. Specifies the date upon which the
deficiencies will be corrected;
(4) If the POC is acceptable, the department
shall issue a certification or provide written notification of acceptance of
the POC, whichever is applicable;
(5) If the POC is not acceptable:
a. The department shall notify the
certificate holder in writing of the reason for rejecting the POC;
b. The certificate holder shall develop and
submit a revised POC within 14 days of the date of the written notification
from the department that states the original POC was rejected unless, within
the 14 day period, the certificate holder requests an extension, either
verbally or in writing, and the department grants the extension, based on the
following criteria:
1. The certificate holder
demonstrates that he or she has made a good faith effort to develop and submit
the POC within the 14 day period but has been unable to do so; and
2. The department determines that the health,
safety, or well being of clients will not be jeopardized as a result of
granting the extension;
c. The revised POC shall comply with (c) (1)
above and be reviewed in accordance with (c) (3) above; and
d. If the revised POC is not acceptable to
the department, or is not submitted within 14 days of the date of the written
notification from the department that states the original POC was rejected,
unless the department has granted an extension, the certificate holder shall be
subject to a directed POC in accordance with (d) below;
(6) The department shall verify the
implementation of any POC that has been submitted and accepted by:
a. Reviewing materials submitted by the
certificate holder;
b. Conducting
an on-site follow-up inspection; or
c. Reviewing compliance during the next
renewal inspection;
(7)
Verification of the implementation of any POC shall only occur after the date
of completion specified by the certificate holder in the plan; and
(8) If the POC or revised POC has not been
implemented by the completion date, at the time of the next inspection the
certificate holder shall be issued a directed POC in accordance with (d)
below.
(d) The
department shall develop and impose a directed POC that specifies corrective
actions for the certificate holder to implement when:
(1) As a result of an inspection or
investigation, deficiencies were identified that require immediate corrective
action to protect the health and safety of the clients or personnel;
(2) A revised POC is not submitted within 14
days of the written notification from the department or such other date as
applicable if an extension was granted by the department; or
(3) A revised POC submitted by the
certificate holder has not been accepted.
(e) If at the time of the next inspection the
directed POC referenced in (d) above has not been implemented by the completion
date stated in the directed POC, the department shall, as appropriate:
(1) Deny the application for a renewal of a
certification; or
(2) Revoke the
certification in accordance with
He-A 304.10(b)
.
(f) The department shall offer an opportunity
for informal dispute resolution to any applicant or certificate holder who
disagrees with a deficiency cited by the department, provided that the
applicant or certificate holder submits a written request for an informal
dispute resolution to the department.
(g) The informal dispute resolution shall be
requested in writing by the applicant, certificate holder, or administrator no
later than 14 days from the date the notice of deficiencies was issued by the
department.
(h) The department
shall change the notice of deficiencies if, based on the evidence presented,
the notice of deficiencies is determined to be incorrect. The department shall
provide a written notice to the applicant or certificate holder of the
determination.
(i) The deadline to
submit a POC in accordance with (c) (2) above shall not apply until the notice
of the determination in (h) above has been provided to the applicant or
certificate holder.
(j) An informal
dispute resolution shall not be available for any applicant or certificate
holder against whom the department has initiated action to suspend, revoke,
deny, or refuse to issue or renew a certification.
#7496, eff 5-23-01; ss by #9476, eff 5-22-09 (from
He-A
304.08)
