Section 220-RICR-80-05-1.7 - Monitoring and Compliance ProceduresA. Compliance Reports - The SEOO requires the health care facility to complete a compliance report annually and upon demand. The information provided by the report will be analyzed for compliance. The health care facility will receive a letter indicating that the compliance report has been received by the SEOO and it is under review. After the information from the compliance report is analyzed, a letter summarizing the compliance report will be sent to the health care facility indicating its results.B. Compliance Problems - If the compliance reports indicated that there were any compliance problems, the summarizing letter will indicate them and their significance;1. Any minor issues will be addressed by recommending a way in which to resolve the problem(s) by letter,2. Any major compliance problem(s) that is identified will be addressed by the SEOO conducting an on-site visit, according to the following procedures.C. On-Site Visit - The health care facility will be notified by letter, in advance of the date of the on-site visit. The notification will also identify the problem(s) that will be reviewed, as well as what documents and information need to be collected in preparation for the visit. An entrance and exit interview will be conducted with the health care facility's appointing authority during the on-site visit. The health care facility will receive the results of the on-site visit. An agreement will be sought to resolve the compliance problem(s).D. Agreements - Any resolution(s) to a compliance problem will be identified in an agreement between the health care facility and the SEOO. Time limits in which to resolve the issue(s) will be a major factor in the agreement. The appropriate regulating department or licensor will be put on notice that there is an agreement in effect between the SEOO and the health care facility.E. Follow-Up and Results - To review the implementation of the resolution(s) contained in the agreement will be conducted. If a health care facility fails to implement the agreement or some part of the agreement or fails to fulfill the agreement within the time factors agreed upon, the SEOO will notify the appropriate regulatory agency or licensee. The regulating/licensor agency will take any action in which it deems necessary.220 R.I. Code R. 220-RICR-80-05-1.7