1. (a) After issuing a notice of non-compliance the department shall impose administrative remedies for violations of He-A 500, including:

   1. (1) Requiring an IDCMP to submit a POC or quality improvement plan (QIP);
   2. (2) Imposing a directed POC upon an IDCMP; or
   3. (3) Withdrawal of an approval to operate an IDCMP or an IDEP, or both.

2. (b) A POC shall be developed and enforced in the following manner:

   1. (1) Upon receipt of a final report outlining the notice of non-compliance, the IDCMP shall submit a POC detailing:

      1. a. How the IDCMP intends to correct each deficiency;
      2. b. Using SMART goals, what measures will be put in place, or what system changes will be made, to ensure that the deficiency does not recur; and
      3. c. The date by which each deficiency shall be corrected;
   2. (2) The IDCMP shall submit a POC to the department within 30 calendar days of the date on the notice in (1) above, unless an extension request, made in writing, has been approved by the department;

   3. (3) The department shall review and accept each POC that:

      1. a. Achieves compliance with He-A 500;
      2. b. Addresses all deficiencies and deficient practices as cited in the written notice described in (1) above, using SMART goals;
      3. c. Prevents a new violation of He-A 500 as a result of the implementation of the POC; and
      4. d. Specifies the date by which the deficiencies shall be corrected;
   4. (4) If the POC is acceptable, the department shall provide written notification of acceptance of the POC;

   5. (5) If the POC is not acceptable:

      1. a. The department shall notify the IDCMP in writing of the reason for rejecting the POC;
      2. b. The IDCMP 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;
      3. c. The revised POC shall comply with (1) above; and
      4. d. If the revised POC is not acceptable to the department the IDCMP shall be subject to a directed POC in accordance with (c) below.

3. (c) The department shall develop and impose a directed POC that specifies corrective actions for the IDCMP to implement, without first requiring a POC that is not directed, when:

   1. (1) As a result of an audit or on-site visit, deficiencies were identified that require immediate corrective action to protect the health and safety of the clients and employees or to ensure the privacy and confidentiality of clients;
   2. (2) A revised POC is not submitted within 14 days of the written notification from the department; or
   3. (3) A revised POC submitted by the IDCMP has not been accepted.
4. (d) The department shall verify the implementation of any POC through on going monitoring.

5. (e) If at the time of the next audit the directed POC has not been implemented by the completion date stated in the POC, the department shall, as appropriate:

   1. (1) Deny an application for a renewal of an approval; or
   2. (2) Withdraw the approval in accordance with He-A 504.09(b).

Source. #10240, eff 1-1-13; ss by #13846, eff 1-6-24, EXPIRES: 1-6-34