Review and Consultation; Substantial Compliance; Plan of Correction

Section 615 Section 615.220  Review and Consultation; Substantial Compliance; Plan of Correction a)         The Department will provide review and consultation to local health departments to evaluate the effectiveness of local health activities and programs and to determine the extent of compliance with the grant agreement. b)         Review and consultation will be provided at least once every three years, or as often as necessary, to assure substantial compliance with this Part and the local health department's grant agreement. c)         During review, the Department will examine records maintained by the local health department to determine substantial compliance for each program by applying specific review criteria to the records examined. 1)         For the infectious diseases program, the Department will use the following criteria to determine that a local health department is in substantial compliance with Section 615.300: A)        At least 75% of the records relating to Section 615.300(b)(2) and (3) and (c)(3), (5) and (9) shall contain documentation of compliance with those subsections. B)        100% of the records relating to Section 615.300(c)(6), (10) and (11) shall contain documentation of compliance with those subsections. 2)         For the food protection program, the Department will use the following criteria to determine that a local health department is in substantial compliance with Section 615.310: A)        At least 75% of the records relating to Section 615.310(b)(3), (4), (7) and (8) and (c)(1), (2) and (3) shall contain documentation of compliance with those subsections. B)        At least 75% of the records relating to all other subsections in Section 615.310 shall contain documentation of compliance with those subsections. 3)         For the potable water supply program, the Department will use the following criteria to determine that a local health department is in substantial compliance with Section 615.320: A)        At least 75% of the records relating to Section 615.320(b)(3), (4), (6), (6)(A) and (B), (7), (8)(A), (B) and (C) and (11) shall contain documentation of compliance with those subsections. B)        At least 75% of the records relating to all other subsections in Section 615.320 shall contain documentation of compliance with those subsections. 4)         For the private sewage disposal program, the Department will use the following criteria to determine that a local health department is in substantial compliance with Section 615.330: A)        At least 75% of the records relating to Section 615.330(b)(4), (5), (6) and (7) shall contain documentation of compliance with those subsections. B)        At least 75% of the records relating to all other subsections in Section 615.330 shall contain documentation of compliance with those subsections. 5)         In addition to the specific review criteria for each program, the Department will use the following criteria to determine that a local health department is in substantial compliance with the common requirements of Section 615.340: A)        The local health department shall comply with the applicable requirements of the Environmental Health Practitioner Licensing Act, as required by Section 615.340(a); and B)        The local health department shall comply with the reporting requirements contained in Section 615.340(d). d)         If the Department determines that a local health department is in substantial compliance with the applicable rules and the grant agreement, the Department will notify the local health department of its determination in writing.  This notification will be made within 90 days after the Department's final determination of compliance. e)         If the Department determines that a local health department is not in substantial compliance with the applicable rules and the grant agreement, the local health department shall develop and follow a written plan of correction acceptable to the Department to achieve substantial compliance. 1)         The Department will notify the local health department of its determination in writing by means of a Notice of Noncompliance that specifies the areas of deficiency to be corrected.  Notification will be made within 90 days after the Department's final determination of noncompliance. 2)         The local health department shall submit a plan of correction to the Department within 30 days after receiving a Notice of Noncompliance. 3)         If the local health department fails to submit a plan of correction that is acceptable to the Department, the Department will prescribe a plan of correction that the local health department shall follow, unless the local health department submits an alternative plan that is acceptable to the Department. 4)         A local health department's failure to follow an approved or prescribed plan of correction may be grounds for suspension or revocation of a grant agreement. The Department will consider the local health department's degree of noncompliance with this Part, the duration of the noncompliance, the local health department's efforts to address the noncompliance, and the extent to which the noncompliance jeopardizes the public's health and safety.