Statement of Deficiencies/Plan of Correction
(1)Statement of Deficiencies. When the Division identifies a facility’s failure to comply with federal regulations, the Division shall document such failure(s) on a federal Statement of Deficiencies form HCFA 2567. The Statement of Deficiencies shall be accompanied by a notification of the informal dispute resolution process.
(2)Plan of Correction.
(a)When Required. Except as otherwise provided by this rule, the facility receiving a Statement of Deficiencies shall develop, submit to the Division, and begin implementing a Plan of Correction (POC) within 10 days of receiving the Statement of Deficiencies. A Plan of Correction is required regardless of whether remedies are imposed. A Plan of Correction is not an enforcement remedy.
(b)Form. The Plan shall be documented on the federal Statement of Deficiencies form HCFA 2567.
(c)Isolated Deficiencies. A Plan of Correction is not required if the Division declares on the Statement of Deficiencies that “the deficiencies are isolated, no harm has resulted, and there is no potential for anything more than minimal harm.”
(d)Approval. All Plans of Correction submitted by a facility are subject to approval by the Division. A facility shall not delay implementation of its Plan of Correction because it has not yet received approval from the Division. If approval is denied, the facility shall have five days to submit an acceptable revised Plan of Correction.
Rule 411-073-0020 — Statement of Deficiencies/Plan of Correction,