Current through Register No. 50, December 12, 2024
Section He-E 807.06 - Plan of Correction(a) A NF with any deficiencies shall submit an acceptable POC before substantial compliance can be determined by the survey agency, except as noted in (b) and (c) below.(b) A POC shall not be required when deficiencies found in a survey are determined to represent no actual harm, with only the potential for minimal harm to residents of the NF.(c) If the deficiencies of a NF are considered to be immediate jeopardy, the POC requirement for submission shall be deferred until the NF has successfully demonstrated the removal of the immediate jeopardy as described in He-E 807.03(c) .(d) A POC submitted by a NF shall contain: (1) The corrective action(s) that will be accomplished by the NF for those residents found to have been affected by the deficient practice;(2) Information on how the NF will identify any other residents who have the potential to be affected by the same deficient practice;(3) The measures the NF will take or the systematic changes the NF will make to ensure the deficient practice will not recur, or both;(4) The date by which each action will be completed or achieved and what steps are required to do so; and(5) Information on how the NF plans to monitor its performance of the POC and how it will achieve and maintain substantial compliance.(e) A POC shall be submitted to the survey agency by the NF within 10 calendar days from the date the NF receives the notice of non-compliance as described in He-E 807.02(b) and (c) .(f) Upon receipt of the POC, the survey agency shall review it to determine if it is acceptable as described in (g) below.(g) A POC shall be acceptable if: (1) It contains all of the informational requirements listed in (d) above; and(2) The corrective action(s) and the dates by which they will be accomplished are reasonable and substantiated by the evidence submitted in the POC and are likely to result in substantial compliance.(h) The survey agency shall notify the NF in writing if: (1) The POC is acceptable; or(2) The POC is not acceptable, indicating: a. The reason(s) why the POC was not accepted; andb. The remedies to be imposed in the timeframes described in He-E 807.03(a) and (b) .(i) Upon acceptance of the POC by the survey agency, the POC shall serve as a basis on which the survey agency conducts a revisit to determine compliance.N.H. Admin. Code § He-E 807.06