Corrective action plan

1. The department shall issue a report requiring the certified clinic to develop a corrective action plan if at any time during the certified community behavioral health clinic certification period, including the renewal process and initial certification, the certified clinic is found to be out of compliance with this chapter. 2. The certified clinic has thirty days to develop and submit a corrective action plan to the department, unless otherwise specified by the department, upon notification by the department of being out of compliance with this chapter. 3. The department has ten days to review a certified clinic's completed and submitted corrective action plan. The department shall notify the certified clinic as to whether the corrective action plan is approved or not approved. If the corrective action plan is: a. Not approved: (1) The certified clinic shall resubmit the updated corrective action plan within ten days of notification that its previous corrective action plan submission was not approved. (2) The department may revoke a certified clinic's certified community behavioral health clinic certification if the certified clinic has submitted the corrective action plan three times without receiving approval, or ninety days have passed from the initial corrective action plan submittal and the corrective action plan is not approved. b. Approved: (1) The certified clinic shall implement the approved corrective action plan. (2) Within ninety days of the corrective action plan approval, the department shall review the certified clinic's implementation of the corrective action plan. (3) Following the review, the department shall notify the certified clinic whether the corrective action plan implementation is approved.