Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 663 - Continuum of Care and Assisted Living › Subchapter 25 - Inspections and Investigations › Section 310:663-25-4 - Notice of violation, plans of correction, and right to hearing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Notice of Violation.
If upon
				survey or investigation the Department finds that the continuum of care
				facility or assisted living center is in violation of the Act or this Chapter,
				the Department shall provide written notice of the violation to the continuum
				of care facility or assisted living center.
(b)
Plan of Correction.
(1) A continuum of care facility or assisted
				living center shall submit a plan of correction within ten (10) Department
				business days after receipt of notice of violation. Failure to timely submit a
				plan of correction shall be subject to the penalties provided in Title 63 O.S.
				Section
				1-890.6.
(2) An acceptable plan of correction shall:
(A) Address how corrective action will be
				accomplished for those residents found to have been affected by the deficient
				practice.
(B) Address how the
				continuum of care facility or assisted living center will identify other
				residents having the potential to be affected by the same deficient practice.
				Plans of correction specific to residents identified on the deficiency
				statement are acceptable only where the deficiency is determined to be unique
				to that resident and not indicative of a possible systemic problem.
(C) Address what measures will be put into
				place or systemic changes made to ensure that the deficient practice will not
				recur.
(D) Indicate how the
				continuum of care facility or assisted living center plans to monitor its
				performance to make sure that corrections are sustained. The continuum of care
				facility or assisted living center shall develop a plan for ensuring that
				correction is achieved and sustained. The actions taken to correct the
				deficient practice must be evaluated for its effectiveness. The plan of
				correction shall be incorporated into the quality assurance system. At the
				revisit, the monitoring records may be reviewed to determine the earliest date
				of compliance. If there is no evidence of evaluation of the correction, the
				earliest correction date will be the date of the revisit. The continuum of care
				facility or assisted living center is not required to provide quality assurance
				minutes for the purposes of this section.
(E) Include dates when corrective action will
				be completed for each violation. The corrective action completion dates shall
				not exceed sixty (60) calendar days from receipt of notice of
				violation.
(F) Be signed by the
				administrator.
(3) Upon
				written request from the continuum of care facility or assisted living center,
				the Department may extend the time period within which the violations are to be
				corrected where correction involves substantial structural
				improvement
.
Such request shall be provided to the Department
				within the timeline specified at 310:663-25-4(b)(1) (relating to submission
				within ten (10) Department business days) or prior to expiration of the
				correction time originally approved. The burden of proof shall be on the
				licensee to show good cause for not being able to comply with the timeline in
				310:663-25-4(b)(2)(E) (relating to correction within sixty (60)
				days).
(4) The Department shall
				provide written notice of the acceptance or rejection of a plan of correction
				within ten (10) Department business days. If the Department fails to provide
				notice of acceptance or rejection within the required time frame, notice will
				be provided as soon as time permits and any delay on the Department's part will
				result in a day for day off-set in any per diem penalty. If the Department
				finds that the plan of correction does not meet the requirements for an
				acceptable plan of correction as specified in this section the Department shall
				provide notice of the rejection and the reason for the rejection to the
				continuum of care facility or assisted living center. The continuum of care
				facility or assisted living center shall have ten (10) Department business days
				after receipt of the notice of rejection in which to submit an amended plan. If
				the amended plan is not timely submitted, or if the amended plan is rejected,
				the Department shall give notice of intent to pursue penalties, as provided in
				Title 63 O.S. Section
				1-890.6.,
				or notice of intent to conduct a revisit to determine if violations
				continue.
(5) Acceptance of the
				plan of correction by the Department does not absolve the continuum of care
				facility or assisted living center of the responsibility for compliance should
				the implementation not result in correction and compliance. Acceptance
				indicates the Department's acknowledgment that the continuum of care facility
				or assisted living center indicated a willingness to make timely
				corrections.
(6) If the violation
				has been corrected prior to submission and approval of a plan of correction,
				the continuum of care facility or assisted living center may submit a report of
				correction in place of a plan of correction. The report of correction shall
				address those requirements specified in this section.
(7) If a continuum of care facility or
				assisted living center desires to contest any Department action under this
				section, it shall send a written request for a hearing to the Hearing Clerk,
				Oklahoma State Department of Health, 1000 NE Tenth Street, Oklahoma City, OK
				73117. The request for hearing shall be submitted within ten (10) Department
				business days of receipt of notice of the contested action.