1. A. If a deficiency is correctable within a specified period of time and does not jeopardize the health or safety of a child, the Licensing Authority may place the agency on a corrective action plan to cure the deficiency in lieu of the disciplinary measures prescribed in R6-5-7419 and R6-5-7420.

2. B. In determining whether to require corrective action in lieu of other disciplinary action, the Licensing Authority shall consider the following criteria:

   1. 1. The nature of the deficiency;
   2. 2. Whether the deficiency can be corrected;
   3. 3. Whether the licensee and its affected staff understand the deficiency and show a willingness and ability to participate in corrective action;
   4. 4. The length of time required to implement corrective action;
   5. 5. Whether the same or similar deficiencies have occurred on prior occasions;
   6. 6. Whether the licensee has had prior corrective action plans, and, if so, the licensee’s success in achieving the required goals of the plan;
   7. 7. The licensee’s history in providing care; and
   8. 8. Other similar or comparable factors demonstrating the licensee’s ability and willingness to follow through with a corrective action plan and avoid future deficiencies.

3. C. The agency shall prepare a corrective action plan for the review and approval of the Licensing Authority.

   1. 1. The plan shall explain:

      1. a. How the agency will remedy the non-compliance;
      2. b. The time periods for completing all corrective action; and
      3. c. The agency staff responsible for carrying out the corrective action plan.
   2. 2. The plan shall provide for the agency to send the Licensing Authority periodic reports on the agency’s progress, and a final report when all corrective action is completed.
   3. 3. An authorized representative of the agency shall sign and date the corrective action plan.

4. D. In deciding whether to approve a plan, the Licensing Authority shall ensure that the plan:

   1. 1. Will correct the identified deficiency within a specified period of time;
   2. 2. Identifies persons responsible for executing the steps listed in the plan; and
   3. 3. Permits the Licensing Authority to monitor the Licensee’s progress in completing the plan.
5. E. The Licensing Authority may conduct announced and unannounced inspections of the agency or facility to monitor implementation of a corrective action plan. The licensee shall cooperate in any monitoring inspection as prescribed in R6-5-7416(C).

Historical Note

Adopted effective July 1, 1997; filed with the Secretary of State’s Office May 15, 1997 (Supp. 97-2).