77 Ill. Adm. Code 280.1050
Notice of Violation and Plan of Correction
Section 280
Section 280.1050Â 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
violations, 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 Each plan of correction shall be based on an assessment by the
hospice program 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 hospice program. Each
plan of correction shall include:
1)Â Â Â Â Â Â Â Â A description of the specific corrective action the hospice
program is taking, or plans to take, to abate, eliminate, or correct the
violation 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 violations and the parties responsible for
the correction.
3)Â Â Â Â Â Â Â Â A specific date by which the corrective action will be
completed.
c)Â Â Â Â Â Â Â Â Submission of a plan of correction shall not be considered an
admission by the hospice program that the violation has occurred.
d)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 appear to 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 hospice program 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 or
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.
e)Â Â Â Â Â Â Â Â The Department shall notify the licensee or applicant in
writing of the rejection of the plan of correction, including specific reasons
for the rejection of the plan. The hospice program shall have 10 days after
receipt of notice of rejection in which to submit a modified plan that
addresses the requirements of subsection (b) of this Section.
f)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 may be specified and imposed by the
Department.
g)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 facility.