§ 52.23. Corrective action plan.

 (a)  The provider shall respond to the written statement of findings under §  52.22 (relating to provider monitoring) with a CAP when requested by the Department.

 (b)  The provider shall submit a CAP to the Department on a form prescribed by the Department.

 (c)  The CAP must contain at least the following:

   (1)  The provider’s name.

   (2)  The provider’s address.

   (3)  The provider’s MA identification number.

   (4)  The action steps to address a specific finding.

   (5)  The dates action steps will be completed.

   (6)  An explanation on how the action steps will remediate the finding.

   (7)  The date when a finding will be remediated.

   (8)  The provider’s signature indicating the provider will implement the CAP.

 (d)  The Department will review and monitor a provider-drafted CAP to ensure each finding is corrected.

 (e)  The Department may reject a provider-drafted CAP and request the provider to revise the CAP so the CAP is in compliance with this section.

 (f)  The Department may develop a CAP for a provider to implement in response to the statement of findings.

 (g)  The provider shall implement a Department-approved CAP.

 (h)  The Department may conduct a follow-up monitoring to ensure the provider is implementing the CAP.

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