Ill. Admin. Code tit. 77 § 340.1230

Current through Register Vol. 48, No. 45, November 8, 2024

Section 340.1230 - Plans of Correction and Reports of Correction

a) The situation, condition, or practice constituting a Type "AA" violation or a Type "A" violation shall be abated or eliminated immediately unless a fixed period of time, not exceeding 15 days, as determined by the Department and specified in the notice of violation is required for correction. (Section 3-303(a) of the Act)

b) The facility shall have ten days after receipt of notice of violation for a Type B violation, or after receipt of a notice of failure to correct a situation, condition, or practice that resulted in the issuance of an administrative warning, to prepare and submit a plan of correction to the Department. (Section 3-303(b) of the Act)

c) Within the 10 day period, a facility may request additional time for submission of the plan of correction. The Department may extend the period for submission of the plan of correction for an additional 30 days, when it finds that corrective action by a facility to abate or eliminate the violation will require substantial capital improvement. The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the residents of the facility in determining whether to grant a requested extension. (Section 3-303(b) of the Act)

d) In lieu of submission of a plan of correction, a facility may submit a report of correction if corrective action has been completed. The report of correction shall be submitted within the time period required in subsections (a) and (b) of this Section.

e) Each plan of correction or report of correction shall be based on an assessment by the facility of the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences. Evidence of such assessment and evaluation shall be maintained by the facility. Each plan of correction or report of correction shall include:

1) A description of the specific corrective action the facility is taking, or plans to take, or has taken to abate, eliminate, or correct the violation cited in the notice.

2) A description of the steps that will be or have been taken to avoid future occurrences of the same and similar violations.

3) A specific date by which the corrective action will be or was completed.

f) Submission of a plan of correction or report of correction shall not be considered an admission by the facility that the violation has occurred.

g) The Department will review each plan of correction or report of correction to ensure that it provides for the abatement, elimination, or correction of the violation. The Department will reject a submitted plan or report only if it finds any of the following deficiencies:

1) The plan or report does not address the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.

2) The plan or report is not specific enough to indicate the actual actions the facility will be taking to abate, eliminate, or correct the violation.

3) The plan or report does not provide for measures that will abate or eliminate, or correct the violation.

4) The plan or report does not provide steps that will avoid future occurrences of the same or similar violations; or

5) The plan or report does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the residents, and the extent and complexity of the corrective action.

h) When the Department rejects a submitted plan of correction or report of correction, it will notify the facility. The notice of rejection shall be in writing and shall specify the reason for the rejection. The facility shall have 10 days after receipt of the notice of rejection to submit a modified plan. (Section 3-303(b) of the Act)

i) If a facility fails to submit a plan or report of correction or modified plan meeting the criteria in subsection (e) of this Section within the prescribed time periods in subsections (a) and (b) or subsection (h) of this Section, or anytime the Department issues a Type AA, Type A or Repeat B violation, the Department will impose an approved plan of correction.

Ill. Admin. Code tit. 77, § 340.1230

Amended at 35 Ill. Reg. 11896, effective June 29, 2011