77 Ill. Adm. Code 210.1500
Notice of Violation and Plan of Correction
Section 210
Section 210.1500Â Notice of
Violation and Plan of Correction
a)Â Â Â Â Â Â Â Â Upon determination that the licensee or applicant is in
violation of the Act or this Part, the Department shall issue a written Notice
of Violation and request a plan of correction. The notice shall specify the
violation(s), and shall instruct the licensee or applicant to submit a plan of
correction to the Department within 10 days after receipt of the Notice.
b)Â Â Â Â Â Â Â Â Within the ten-day period, a licensee or applicant 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 the Department finds that corrective action by the Model to abate or
eliminate the violation(s) 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 patients of the Model in determining whether to grant a requested
extension.
c)Â Â Â Â Â Â Â Â Each plan of correction shall be based on an assessment by the
Model of the conditions or occurrences that are the basis of the violation(s)
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 Model. Each plan of correction shall
include:
1)Â Â Â Â Â Â Â Â A description of the specific corrective action the Model is
taking, or plans to take, to abate, eliminate, or correct the violation(s)
cited in the Notice;
2)Â Â Â Â Â Â Â Â A description of the steps that will be taken to avoid future
occurrences of the same and similar violation(s); and
3)Â Â Â Â Â Â Â Â A specific date by which the corrective action will be
completed.
d)Â Â Â Â Â Â Â Â Submission of a plan of correction shall not be considered an
admission by the Model that the violation(s) has occurred.
e)Â Â Â Â Â Â Â Â The applicant or licensee may submit additional information in
response to the Notice of Violation that it believes will clarify the condition
or alleged violation(s). The Department will consider the information in
reviewing the applicant's or licensee's response and the plan of correction.
f)Â Â Â Â Â Â Â Â The Department shall review each plan of correction to ensure
that it provides for the abatement, elimination, or correction of the
violation. The Department shall reject a submitted plan only if it finds any
of the following deficiencies:
1)Â Â Â Â Â Â Â Â The plan 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)Â Â Â Â Â Â Â Â The plan is not specific enough to indicate the actual actions
the Model will be taking to abate, eliminate, or correct the violation.
3)Â Â Â Â Â Â Â Â The plan does not provide for measures that will abate,
eliminate, or correct the violation.
4)Â Â Â Â Â Â Â Â The plan does not provide steps that will avoid future
occurrences of the same and similar violations.
5)Â Â Â Â Â Â Â Â The plan does not provide for timely completion of the
corrective action, considering the seriousness of the violation, any possible
harm to the patients, and the extent and complexity of the correction action.
g)Â Â Â Â Â Â Â Â The Department shall notify the licensee or applicant if the
plan of correction is rejected, including specific reasons for the rejection of
the plan. The Model shall submit a modified plan that addresses the
requirements of subsection (c) of this Section within five days after receipt
of notice of rejection.
h)Â Â Â Â Â Â Â Â If a licensee or applicant fails to make a timely submission
of a modified plan of correction, or such modified plan is not acceptable to
the Department, a plan of correction shall be specified and imposed by the
Department.
i)Â Â Â Â Â Â Â Â Â The Department shall verify the completion of the corrective
action required by the plan of correction within the specified time period
during subsequent investigations, surveys, and evaluations of the Model.