1. (a) The unit shall issue a statement of findings to the applicant or licensee for each licensing and monitoring visit, and each investigatory visit which results in non-compliance with any of the provisions of RSA 170-E or He-C 4001.
2. (b) At the close of any visit or when an investigation is concluded, or as soon as possible thereafter, the unit shall review with the program director or their designee, a summary of any citations of rules found during the visit.
3. (c) Within 21 calendar days of the review in (b) above, the unit shall provide the statement of findings via email, by uploading to the program’s NHCIS portal, if applicable, or by U.S. mail if an email address has not been provided.
4. (d) The program shall not alter the statement of findings, including but not limited to revising evidence or dates as documented by the unit.

5. (e) The program director or their designee shall submit a corrective action plan for each citation included on the statement of findings, and include:

   1. (1) The action the program has taken or shall take to correct the citations, including any interim measures implemented to protect the health and safety of residents pending correction of the non-compliance;
   2. (2) What measures or systemic changes the program shall implement to ensure that the non-compliance does not recur;
   3. (3) The date by which the program corrected or shall correct each citation; and
   4. (4) The dated signature of the program director or their designee when the corrective action plan is submitted in writing.

6. (f) The program director or their designee shall complete corrective action plans and return them to the unit in accordance with the following:

   1. (1) The corrective action plan shall be submitted to the unit within 21 calendar days of the date the unit issues the statement of findings; and
   2. (2) The names of individuals shall not be included in the corrective action plans.

7. (g) The only exceptions to (f)(1) above shall be as follows:

   1. (1) When a program director or their designee requests an informal dispute resolution in accordance with He-C 4001.08, the corrective action plan due date shall be 21 calendar days from:

      1. a. The date the program receives notice of the unit’s decision regarding the informal dispute resolution if the unit is not issuing a revised statement of findings; or
      2. b. The date the unit issues the revised statement of findings as a result of the informal dispute resolution; and
   2. (2) When the program director or their designee requests and receives an extension from the unit, when a corrective action plan cannot be completed and returned by the due date.
8. (h) When the corrective action plan submitted to the unit by the program in accordance with (e) and (f) above is not acceptable, the unit shall notify the licensee in writing of the reason for rejecting the proposed corrective action plan and request submission of a new corrective action plan.
9. (i) When a program fails to submit an acceptable corrective action plan, the unit shall create and issue an acceptable corrective action plan, and the program shall return and implement the corrective action plan in accordance with (e) and (f) above.

10. (j) The unit shall verify implementation of the corrective action plan submitted and approved by the unit by:

    1. (1) Reviewing materials submitted by the licensee;
    2. (2) Conducting a follow-up inspection; or
    3. (3) Reviewing compliance during any subsequent visit conducted in accordance with RSA 170-E:31, IV, RSA 170-E:32, II, or RSA 170-E:40, II.
11. (k) When the findings of any inspection or investigation indicate that immediate corrective action is required to protect the health and safety of the residents or personnel, the unit shall order the immediate implementation of a directed corrective action plan developed by the unit.
12. (l) The existence of a corrective action plan shall not prohibit the department from taking other enforcement action available to it under He-C 4001, RSA 170-E, RSA 541-A, or other law.
13. (m) The department shall initiate enforcement action without requesting that the program submit a corrective action plan when it finds repeat non-compliance with licensing rules or statute, or when it finds non-compliance with a rule or statute resulted in physical injury to a resident or caused a resident to be in danger of physical injury.
14. (n) Programs shall comply with approved corrective action plans and corrective action plans issued in accordance with (i) and (k) above.
15. (o) Programs shall maintain on file on the premises and make available upon request to clients and perspective clients, a copy of the statement of findings and corrective action plan approved or issued by the unit for the visit immediately preceding the visit represented on the last statement of findings issued.
16. (p) All statements of findings issued for non-compliance with any of the provisions of RSA 170-E or He-C 4001, and the corrective action plans submitted in response to those citations shall be considered public information on or after the corrective action plan due date as specified herein.

Source. #2664, eff 3-30-84, EXPIRED: 3-30-90 New. #8581, eff 4-20-06, EXPIRED: 4-20-14 New. #10576, INTERIM, eff 4-26-14, EXPIRES: 10-23-14; ss by #10705, eff 10-23-14; ss by #14214, eff 4-1-24