Bureau of Assisted Living: No Plan of Correction Initiative

DHS Logo Original 07/11/2018

Division of Quality Assurance: Assisted Living

Attn: Assisted Living Providers

Bureau of Assisted Living: No Plan of Correction Initiative

The Bureau of Assisted Living (BAL) has regularly required assisted living providers to submit a Plan of Correction (POC) when issued Statement of Deficiency (SOD) that contains violations following a survey. The POC describes the action the assisted living provider will take to address the issued violations, how they will maintain regulatory compliance, and a date of completion for correcting each violation(s).

Effective October 1, 2020, in an effort to improve the Bureau’s efficiency and better align its resources in regulating assisted living facilities, BAL will no longer regularly require the provider to submit a POC when issued an SOD. The No POC Initiative shall apply to all issued SODs that result in violations of state regulations, excluding deficiencies issued to certified Residential Care Apartment Complexes (RCAC).

As part of the Bureau’s focus on quality improvement in assisted living, the provider should have an internal system in place to respond to an SOD. The surveyor may offer focused technical assistance to the provider and recommend they implement an internal system that contains all of the following:

  • What corrective action and system changes will be made to ensure violations are corrected and regulatory compliance is maintained?
  • Who is responsible for monitoring for continued regulatory compliance?
  • Date of completion for each corrective action (Violation, Order).
  • Providers should not rely solely on Bureau inspections to identify non-compliance. Internal quality improvement processes should assist the facility in proactively identifying and addressing non-compliance and improving consumer satisfaction.

The Bureau will retain the option to utilize an order for a POC on an as needed basis for all provider types as determined by the Bureau. In lieu of submitting a POC, it is the Bureau’s expectation that assisted living facilities will continue to evaluate systems to ensure continued compliance with applicable regulations. To learn more about the Bureau of Assisted Living Survey Process, please visit the Assisted Living Survey Guide webpage.