c) On-site Certification

1. 1) The CSA shall perform an on-site review within the provisional certification period outlined in Section 132.95(f) to confirm the findings of the provisional certification determination. If the CSA determines the CSP or CMHC to be:

   1. A) In compliance, the CSA shall notify the CSP or CMHC. For providers enrolled in the IMPACT system, the CSA shall notify HFS of the change in certification status from provisional to full certification.
   2. B) Not in compliance, the CSA shall issue the CSP or CMHC a Notice of Violation within 15 days after the on-site review. The entity shall respond to the NOV by the due date indicated on the NOV, which shall be approximately 30 days after the date of the NOV.
2. 2) The CSP or CMHC shall submit notice and a Plan of Correction to the CSA to address all identified violations by the due date indicated on the NOV.
3. 3) If the notice and Plan of Correction is found to address all of the identified violations, the CSA shall assure implementation of the Plan of Correction. The program certification status must be in "good standing" with the CSA. The CSA shall notify the CSP or CMHC of the change in certification status from provisional to full certification. For entities enrolled in the IMPACT Portal, the CSA shall notify HFS of the change in certification status from provisional to full certification.
4. 4) If the CSP or CMHC fails to supply a Plan of Correction or fails to implement its approved Plan of Correction and is "not in good standing" with the CSA, as detailed in this Part, the CSA shall notify the entity in writing of its failure to retain certification and right to appeal pursuant to Section 132.100. For entities enrolled in IMPACT, the CSA shall also notify HFS of the entity's failure to retain certification.
5. 5) If the CSA finds evidence of suspected fraud or abuse relating to Medical Assistance, the CSA shall refer that evidence to HFS-OIG for further action.