77 Ill. Adm. Code 340.1230
Plans of Correction and Reports of Correction
Section 340
Section 340.1230Â Plans of
Correction and Reports of Correction
a)
The
situation, condition, or practice constituting a Type "AA" violation
or a Type "A" violation shall be abated or eliminated immediately
unless a fixed period of time, not exceeding 15 days, as determined by the
Department and specified in the notice of violation is required for correction
.Â
(Section 3-303(a) of the Act)
b)
The facility shall have ten days after receipt of notice of
violation
for a Type B violation, or after receipt of a notice of failure
to correct a situation, condition, or practice that resulted in the issuance of
an administrative warning,
to prepare and submit a plan of correction
to
the Department. (Section 3-303(b) of the Act)
c)Â Â Â Â Â Â Â Â Within the 10-day period, a facility 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
it finds that corrective action by a facility to abate or eliminate the
violation 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 residents
of the facility in determining whether to grant a requested extension. (Section
3-303(b) of the Act)
d)
No person shall intentionally fail to correct or interfere
with the correction of a Type "AA", Type "A", or Type
"B" violation within the time specified on the notice or approved
plan of correction under
the
Act as the maximum period given for
correction, unless an extension is granted
pursuant to subsection (c)
and the corrections are made before expiration of extension. A violation of
this
subsection
is a business offense, punishable by a fine not to
exceed $10,000, except as otherwise provided in subsection (2) of Section 3-103
of
the
Act
and Section 340.1130(b)(8)
as to submission of false
or misleading information in a license application.
(Section 3-318 (a)(1)
and (b) of the Act)
e)Â Â Â Â Â Â Â Â In lieu of submission of a plan of correction, a facility may
submit a report of correction if corrective action has been completed. The report
of correction shall be submitted within the time period required in subsections
(a) and (b) of this Section.
f)Â Â Â Â Â Â Â Â Each plan of correction or report of correction shall be based
on an assessment by the facility 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.Â
Evidence of the assessment and evaluation shall be maintained by the facility.Â
Each plan of correction or report of correction shall include:
1)Â Â Â Â Â Â Â Â A description of the specific corrective action the facility
is taking, or plans to take, or has taken 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 or have been taken to
avoid future occurrences of the same and similar violations.
3)Â Â Â Â Â Â Â Â A specific date by which the corrective action will be or was
completed.
g)Â Â Â Â Â Â Â Â Submission of a plan of correction or report of correction will
not be considered an admission by the facility that the violation has occurred.
h)Â Â Â Â Â Â Â Â The Department will review each plan of correction or report
of correction to ensure that it provides for the abatement, elimination, or
correction of the violation. The Department will reject a submitted plan or
report only if it finds any of the following deficiencies:
1)Â Â Â Â Â Â Â Â The plan or report 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 or report is not specific enough to indicate the
actual actions the facility will be taking to abate, eliminate, or correct the
violation.
3)Â Â Â Â Â Â Â Â The plan or report does not provide for measures that will
abate, eliminate, or correct the violation.
4)Â Â Â Â Â Â Â Â The plan or report does not provide steps that will avoid
future occurrences of the same or similar violations; or
5)Â Â Â Â Â Â Â Â The plan or report does not provide for timely completion of
the corrective action, considering the seriousness of the violation, any
possible harm to the residents, and the extent and complexity of the corrective
action.
i)Â Â Â Â Â Â Â Â Â When the Department rejects a submitted plan of correction or
report of correction, it will notify the facility. The notice of rejection
shall be in writing and shall specify the
reason for the rejection
.
The
facility shall have
10
days after receipt of the notice of rejection to
submit a modified plan
. (Section 3-303(b) of the Act)
j)Â Â Â Â Â Â Â Â Â If a facility fails to submit a plan or report of correction
or modified plan meeting the criteria in subsection (f) within the prescribed
time periods in subsections (a) and (b) or subsection (j), or anytime the
Department issues a Type AA, Type A or Repeat B violation, the Department will
impose an approved plan of correction.