55 Pa. Code § 52.23 – Corrective action plan.

(a) The provider shall respond to the written statement of findings under § 52.22 (relating to provider monitoring) with a CAP when requested by the Department.
(b) The provider shall submit a CAP to the Department on a form prescribed by the Department.
(c) The CAP must contain at least the following:
1. (1) The provider’s name.
2. (2) The provider’s address.
3. (3) The provider’s MA identification number.
4. (4) The action steps to address a specific finding.
5. (5) The dates action steps will be completed.
6. (6) An explanation on how the action steps will remediate the finding.
7. (7) The date when a finding will be remediated.
8. (8) The provider’s signature indicating the provider will implement the CAP.
(d) The Department will review and monitor a provider-drafted CAP to ensure each finding is corrected.
(e) The Department may reject a provider-drafted CAP and request the provider to revise the CAP so the CAP is in compliance with this section.
(f) The Department may develop a CAP for a provider to implement in response to the statement of findings.
(g) The provider shall implement a Department-approved CAP.
(h) The Department may conduct a follow-up monitoring to ensure the provider is implementing the CAP.