Current through Reg. 49, No. 38; September 20, 2024
(a) DADS may impose a directed plan of
correction (DPoC) on one or more of a program provider's facilities, a vendor
hold on payments due under one or more of a program provider's agreements, or
both if:
(1) the program provider is
determined as a result of an inspection or survey to not meet one or more of
the federal ICF/IID standards of participation (SoPs) or conditions of
participation (CoPs) and DADS determines that the program provider's failure to
meet such SoPs or CoPs resulted in or may result in serious injury to or death
of an individual residing in the program provider's facility;
(2) the program provider is determined as a
result of an inspection or survey to not meet one or more of the SoPs and DADS
determines that the program provider's failure to meet such SoPs indicates a
pervasive lack of active treatment;
(3) the program provider is determined as a
result of an inspection or survey to not meet one of more of the SoPs or CoPs
or to not be compliant with one or more state rules applicable to the ICF/IID
program and DADS determines, based on its review of previous inspection or
survey findings related to the program provider, that the program provider's
failure to meet the SoPs or CoPs or noncompliance with state rules indicates:
(A) a pattern of error in a particular
discipline, such as nursing or psychology; or
(B) deficient program provider practices or
procedures, such as inadequate staffing or insufficient staff training;
or
(4) it is determined:
(A) during a follow-up certification review
that the program provider failed to correct previous findings of the survey and
did not meet one or more additional SoPs, CoPs, or state rules; and
(B) that the program provider's continued
failure to meet the SoPs, CoPs, or state rules indicates significant deficient
practices that resulted in or may result in serious injury to or death of an
individual residing in the program provider's facility.
(b) When making a determination in
accordance with subsection (a) of this section, DADS reviews the inspection or
survey reports documenting the program provider's failure to meet the SoPs,
CoPs, or state rules, which may include a description of:
(1) the situation or occurrence that led to
the deficiency;
(2) the program
provider's response to the situation or occurrence; and
(3) the program provider's practices at the
time of the situation or occurrence.
(c) DADS imposes a DPoC or vendor hold in
accordance with subsection (a) of this section only on a facility that has been
determined to meet the criteria described in subsection (a)(1), (2), (3), or
(4) of this section.
