- (a) A finding of “Does Not Meet Standard” with one or more standards shall trigger a 180-day corrective action period.
- (b) The auditor and the agency shall jointly develop a corrective action plan to achieve compliance.
- (c) The auditor shall take necessary and appropriate steps to verify implementation of the corrective action plan, such as reviewing updated policies and procedures or re-inspecting portions of a facility.
- (d) After the 180-day corrective action period ends, the auditor shall issue a final determination as to whether the facility has achieved compliance with those standards requiring corrective action.
- (e) If the agency does not achieve compliance with each standard, it may (at its discretion and cost) request a subsequent audit once it believes that is has achieved compliance.