Section He-C 4001.06 - Statements of Findings and Corrective Action Plans(a) The department shall issue a statement of findings to the program when it determines that the program has one or more violations of any of the provisions of RSA 170-E or He-C 4001.(b) The program director or designee shall complete a written corrective action plan for each violation included on the statement of findings.(c) The corrective action plan required in (b) above shall describe: (1) How the licensee intends to correct each violation including any interim measures the program director or designee has implemented to protect the health and safety of residents until the violation can be corrected;(2) What measures will be put in place, or what systemic changes will be made to ensure that the violation does not recur; and(3) The date by which each violation was corrected or will be corrected.(d) The program director or designee shall complete corrective action plans and return them to the department in accordance with the following: (1) The corrective action plan shall not include the names of individuals; and(2) The statement of findings and corrective action plan shall be: a. Signed and dated by the program director or designee; andb. Returned to the department no later than 3 weeks from the date the statement of findings is sent out by the department.(e) The program director or designee shall not alter the statement of findings or corrective action plan once it has been submitted to the department.(f) The only exceptions to (d) (2) b. above shall be as follows: (1) When a program director or designee requests an informal dispute resolution in accordance with He-C 4001.08, the corrective action plan due date shall be 3 weeks from: a. The date the program receives notice of the department's decision regarding the informal dispute resolution if the department is not issuing a revised statement of findings; orb. The date the department issues the revised statement of findings as a result of the informal dispute resolution; and(2) A program director or designee who cannot complete and return a corrective action plan by the due date may request and receive an extension from the department.(g) The criteria for acceptability shall be whether the corrective action plan, when implemented, will achieve compliance with RSA 170-E and He-C 4001.(h) The department shall reject a corrective action plan when the plan fails to: (1) Achieve compliance with RSA 170-E, He-C 4001, or any other applicable licensing rules;(2) Address the violation as written;(3) Address all violations cited on the statement of findings;(4) Prevent a new violation of RSA 170-E, He-C 4001, or any other applicable law; or(5) State a completion date.(i) When the corrective action plan submitted to the department by the program in accordance with He-C 4001.06(d) and (f) above is not acceptable, the department shall notify the licensee in writing of the reason for rejecting the proposed corrective action plan and: (1) Attempt to resolve the problem through a telephone consultation with the executive director or program director, when the unacceptable corrective action plan needs only simple, minor modifications or additions to make it acceptable; or(2) Issue a revised corrective action plan to the program with a notice advising the program why the original corrective action plan submitted by the program is not acceptable.(j) When a program is issued a revised corrective action plan, it shall: (1) Make any revisions to the corrective action plan as approved by the department; and(2) Return and implement the revised corrective action plan in accordance with He-C 4001.06(d) above.(k) The department shall verify that a corrective action plan, as submitted and accepted, has been implemented by any of the following: (1) Reviewing materials submitted by the licensee;(2) Conducting a follow-up inspection; or(3) Reviewing compliance during any subsequent visit conducted in accordance with RSA 170-E:31, IV, RSA 170-E:32, II or RSA 170-E:40, II.(l) When the findings of any inspection or investigation indicate that immediate corrective action is required to protect the health and safety of the residents or personnel, the department shall order the immediate implementation of a directed corrective action plan developed by the department.(m) The existence of a corrective action plan shall not prohibit the department from taking other enforcement action available to it under He-C 4001, RSA 170-E, RSA 541-A or other law.(n) All statements of findings issued for violations of any of the provisions of RSA 170-E or He-C 4001, and the corrective action plans submitted in response to those violations shall be considered public information on or after the corrective action plan due date as specified in (d) (2) b. and (f) (1) and (2) above.(o) An applicant or licensee may appeal a violation cited on a statement of findings, only as part of an adjudicatory process regarding enforcement action taken against a license.N.H. Admin. Code § He-C 4001.06
#2664, eff 3-30-84, EXPIRED: 3-30-90
New. #8581, eff 4-20-06, EXPIRED: 4-20-06
New. #10576, INTERIM, eff 4-26-14, EXPIRES: 10-23-14
Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10705, Effective 10/23/2014, Expires10/23/2024.