Section 70. Development of a plan of action

A. A plan of action shall be developed for all deficiencies noted in the compliance audit findings. The plan of action must identify the following:

1. The tasks required to correct a noted deficiency;

2. The personnel responsible for completing the tasks; and

3. The actual or proposed date of task completion.

B. The facility or program administrator shall submit the plan of action to the Compliance and Accreditation Unit within 10 working days of receipt of the notification of deficiencies.

C. The Compliance and Accreditation Unit manager shall

approve, amend, or return the plan of action to the facility or program administrator for revision within 10 working days of receipt.

D. The facility or program administrator shall complete any revision requested and return the plan to the Compliance and Accreditation Unit manager within 10 working days of receipt.

E. The Compliance and Accreditation Unit manager may grant one 30-day extension to a facility or program administrator for the development of a plan of action. The Compliance and Accreditation Unit manager shall notify the board of the extension and its justification. The board may grant additional extensions.

F. If a facility or program administrator fails to submit a plan of action within the time specified, the Compliance and Accreditation Unit supervisor shall submit the audit report with recommendations to the board.

Historical Notes

Derived from VR230-01-003:1 § 2.5, eff. May 1, 1993; amended, Volume 13, Issue 17, eff. July 1, 1997; Volume 23, Issue 22, eff. August 9, 2007; Volume 28, Issue 06, eff. December 21, 2011.

Statutory Authority

§ 53.1-5 of the Code of Virginia.