36.07.02.16

.16 Corrective Action.

A. Deficiency.

(1) Assess the seriousness of the deficiency;

(2) Require the licensee to develop a corrective action plan;

(3) Determine whether it is necessary during the pendency of the corrective action process to emergently suspend the license;

(4) Evaluate and, if acceptable to the Agency, approve the corrective action plan;

(5) Determine appropriate timelines for the completion of corrective action;

(6) Conduct periodic monitoring of a licensee for which the Agency required a corrective action plan to assess the licensee’s progress toward remedying the deficiencies; and

(7) Recommend that the Commission impose a sanction under Regulation .17 of this chapter if a deficiency is not remedied through implementation of corrective action.

B. Deficiency Notice.

(1) A description of the violation;

(2) A description of the possible sanctions; and

(3) The requirement for the licensee to submit a corrective action plan to the Director within a time frame established by the Director.

C. Corrective Action Plan.

(1) Within 10 days of receipt of a deficiency notice under §B of this regulation, the licensee shall submit a corrective action plan to the Director for the Director’s approval.

(2) The Director shall review the corrective action plan and inform the licensee whether the corrective action plan is acceptable.

(3) If the licensee fails to submit an acceptable corrective action plan within the time described under §C(1) of this regulation, the Director may:

(a) Provide the licensee with additional time within which to submit a revised corrective action plan; or

(b) Impose a sanction on the licensee under Regulation .17 of this chapter.

(4) If the Director provided a licensee notice under §B(3) of this regulation and received no timely written response, the Commission may adopt as final the Director’s decision to impose a sanction under Regulation .17 of this chapter.

D. Corrective Action Outcomes.

(1) If at any time during the corrective action period the Director determines that the licensee has failed to fulfill a requirement of the corrective action plan or has made insufficient progress toward remedying a deficiency, the Director may:

(a) For good cause, extend the time for completion of a corrective action plan; or

(b) Emergently suspend the licensee’s license.

(2) If at the end of the corrective action period the licensee has failed to adequately remedy a deficiency, the Director may impose a sanction under Regulation .17 of this chapter.