77 Ill. Adm. Code 390.278
Plans of Correction
Section 390
Section 390.278Â Plans 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
. (Section 3-303(a) of the Act)
b)
The facility shall have 10 days after receipt of
notice
of violation
for a Type "B" violation, or after receipt of a
notice under Section 390.277(e) 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 will 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 extension 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 (d)
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 390.120(c)
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 Each plan or 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. The facility shall maintain
evidence of the assessment and evaluation. Each plan 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, 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
3)Â Â Â Â Â Â Â Â A specific date by which the corrective action will be
completed.
f)Â Â Â Â Â Â Â Â Submission of a plan of correction shall not be considered an
admission by the facility that the violation has occurred.
g)Â Â Â Â Â Â Â Â The Department will review each plan of correction to ensure
that it provides for the abatement, elimination, or correction of the
violation. The Department will 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 facility 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; or
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 residents, and the extent and complexity of the corrective action.
h)Â Â Â Â Â Â Â Â When the Department rejects a submitted plan 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
in which
to submit a
modified plan
. (Section 3-303(b) of the Act)
i)Â Â Â Â Â Â Â Â Â If a facility fails to submit a plan or modified plan meeting
the criteria in subsection (e) within the prescribed time periods in subsection
(b) or (c), or anytime the Department issues a Type "AA", a Type "A",
or repeat Type "B" violation, the Department will impose an approved
plan of correction.
j)Â Â Â Â Â Â Â Â Â The Department will 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.