.Provider will submit corrective action plan to the department within 15 business days…. An immediate corrective action plan shall be required if the department determines that the violations pose a danger to individuals receiving the service. GUIDANCE: If the provider fails to suggest a CAP during the inspection, the specialist will suggest one for them.

1. 1. 1. What if the specialist suggests a CAP that is not possible within in the abilities of the agency? If a CAP is generated at the time of the inspection, is there any way for the agency to dispute the citation during/after the inspection?

F. Dispute Resolution (Guidance) – page 6 first bullet point indicates that the information will be discussed with the Associate Director and Director to make a final decision; second bullet point indicates that the decision will be made by Licensing Specialist Supervisor in consultation with Director or Associate Director; third bullet point indicates that the Director or Associate Director will issue a final decision.

1. 1. 1. Should these match and  be “or” versus “and”?
      2. If the Licensing Specialist Supervisor is the one making the decision, why is it the Director or Associate Director issuing the decision?