AGING AND DISABILITY SERVICES ADMINISTRATION

Residential Care Services
Operational Principles and Procedures For An Acceptable Written Plan of Correction

1. Purpose
   
   To implement statutes and regulations regarding the Department of Social and Health Services' (the department's) authority to give a licensee an opportunity to submit a plan to correct deficiency citations and to advise the department of the licensee's progress correcting cited deficiencies.
   
   
2. Authority
   
   WAC 388-78A-030(1) BH Minimum Licensing Requirements
   
   
3. Operational Principles
   
   
   1. Oral notice of findings during inspections should be given to the licensee by RCS staff when possible and appropriate. Licensees should begin initiating corrective action in response to deficiencies cited upon oral notice of findings during inspections.
   2. Licensees will be given an opportunity to submit an acceptable, written Plan of Correction (POC) in response to deficiency citations on Statement of Deficiencies (SOD) reports unless the department initiates revocation or suspension of the license.
   3. Licensees will be informed of the elements to be included in an acceptable, written Plan of Correction in a cover letter attached to a completed SOD report.
   4. An acceptable, written Plan of Correction must be submitted to the department within ten calendar days after the licensee's receipt of the SOD report.
   5. Licensee correction dates may be designated by the department if a threat to resident health/safety exists or when a condition on a license has been initiated.
   6. Timeframes identified within this procedure to complete and process a licensee's acceptable plan of correction are intended as a guide to staff and may be extended with management's approval, except as otherwise specified in statute or regulation.
   7. Acceptability of a licensee's Plan of Correction should be determined by the department within five working days of receipt in the Unit office.
   8. Acceptable Plan(s) of Correction submitted by the Licensee will be incorporated into the SOD report and the entire document will be retained in the licensee's file.
   9. Licensees may specify in the Plan of Correction that they are not in agreement with findings within the SOD report; however, this does not alter licensees' responsibility to submit an acceptable, written Plan of Correction for each deficiency citation written unless otherwise specified.
   10. Licensee plans of correction may be reviewed by Regional Administrators for any purpose including, but not limited to, quality assurance activities and information sharing within RCS' management structure.
       
       
4. Procedure
   
   
   1. On-Site Licensee Plan of Correction Notification
      1. RCS staff should:
         1. Inform the licensee prior to leaving the home that a SOD report will be sent to the licensee within 10 working days of completion of data collection.
         2. Inform the licensee prior to leaving the home that an acceptable, written plan of correction, including six elements for each deficiency citation, must be returned to the department within ten calendar days of receipt of the SOD report. Licensee should enter POC for each citation on SOD or reference an attached document.
         3. When necessary to protect resident health, safety or welfare, and with Field Manager and Enforcement Officer approval, obtain a plan of correction from the licensee prior to leaving the home.
   2. Off-Site Licensee Plan of Correction Review
      1. RCS staff should:
         1. Verify that the licensee's Plan of Correction is received within ten calendar days after receipt of the SOD.
         2. If the Plan of Correction is not received within ten (10) calendar days, contact the licensee via telephone and request the completed Plan of Correction.
         3. Review the licensee's Plan of Correction within five working days of receipt in the Unit office. Confirm that the Plan of Correction for each deficiency includes:
            1. How the home will correct the deficiency for each numbered resident;
            2. How the home will protect residents in similar situations;
            3. Measures the home will take or the systems it will change to ensure that the problem does not recur;
            4. How the home plans to monitor its ongoing performance to sustain compliance;
            5. Dates corrective action will be completed which do not exceed forty five (45) days from the last day of the onsite; and
            6. The title of the person responsible for correction.
         4. When acceptable, notify the Field Manager and Support Staff via e-mail that the licensee's Plan of Correction is "acceptable".
            OR
         5. If the plan of correction is not acceptable, contact the licensee via telephone. Address issues related to the submitted Plan of Correction that are "not acceptable." Submit a "not acceptable" Plan of Correction letter for Field Manager signature. See Attachment #1.
            1. Minor changes to the POC may be written on the submitted document with the licensee's permission and a copy of the corrected, acceptable POC will then be sent to the licensee.
            2. Major changes to the POC require resubmission of an acceptable POC by the licensee to the department within five working days of the licensee's receipt of the "not acceptable" POC letter.
   3. Regional Management Review of Licensee Plan of Correction
   1. Field Managers should:
      1. Sign and send via certified mail a "not acceptable" Plan of Correction letter to the licensee.
      2. Contact the licensee when an acceptable, written Plan of Correction is not resubmitted to the department within five working days.
      3. Meet with the licensee to:
         1. review the department's concerns related to the licensee's failure to submit an acceptable, written Plan of Correction; and,
         2. obtain an acceptable Plan of Correction (dates of correction should not exceed forty-five (45) days from the last date of the onsite inspection visit).
      4. Forward the inspection packet to support staff for processing and distribution of the final SOD/Plan of Correction to Enforcement Officers (if an enforcement action has been taken) when an acceptable Plan of Correction is received.
         OR
      5. Initiate recommendation for enforcement action when the licensee is unable or unwilling to comply with the Plan of Correction requirement.

Date: 02-28-02
Patricia K. Lashway, Director
Residential Care Services

ATTACHMENT #1:

SAMPLE "NOT ACCEPTABLE POC" COVER LETTER

DATE
CERTIFIED MAIL

____________________, (Administrator/Owner/Program Director)
____________________ (Home Name, License #)
____________________ (Home Address)
____________________

Dear Mr./Ms.__________:

On _______________, a Plan of Correction was received from you in response to the department's Statement of Deficiencies report dated ____________. As discussed with you by telephone, the department finds that your Plan of Correction is not acceptable.

Your Plan of Correction should include:

• How the home will correct the deficiency for each numbered resident;
• How the home will protect residents in similar situations;
• Measures the home will take or the systems it will change to ensure that the problem does not recur;
• How the home plans to monitor its ongoing performance to sustain compliance;
• Dates when corrective action will be completed (no more than 45days from the last day of the inspection); and,
• The title of the person responsible to ensure correction.

Please revise your Plan of Correction to include the following elements:

• (identify specific WAC or RCW) - identify specific elements not included in POC

Example: WAC XXX-XXX-XXX - no POC date and title of responsible person identified.

I am returning the Statement of Deficiencies report dated ___________ to you. Please provide an acceptable, written Plan of Correction for each deficiency citation in accordance with the above criteria within five working days of receipt of this letter. The department may be forced to impose additional citations and/or an enforcement action against you for your failure to timely and appropriately correct deficiencies or provide an acceptable Plan of Correction.

If you have any questions, please contact me at (phone).

Sincerely,

_______________, Field Manager
Region ___, Unit ___
Residential Care Services

cc: Region File