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What you need › Webinar notes › CDSS Community Care Licensing

Plan of Correction

December 2023On-demand webinar23:11 long

Presented December 2023. Rules and deadlines may have changed since; check Rules & laws for the current version.

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A licensing technical support webinar on plans of correction: writing one, due dates and extensions, proving the fix, and appeals.

Hosted by

CDSS Community Care Licensing

Presented by

CDSS Technical Support Program

Who it’s for

  • Licensed family child care homes
  • Child care centers
  • All Community Care Licensing facility types

3 things to know

  1. After a deficiency citation you must write a plan of correction, with your LPA's help; it goes in your public file.
  2. A good plan is meaningful, measurable, verifiable and time-sensitive: it fixes the problem and keeps it from coming back.
  3. You are encouraged to keep working on your plan even if you appeal; it stays in effect unless licensing says otherwise in writing.

Do this

If you can't meet a correction due date, ask your LPA or regional office in writing, with your reasons, before it's due.

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What to do

Session notes

In the order it was presented. Open any part.

Why plans of correction matter
  • The presenter said plans of correction are a required part of being licensed.▶ 00:02:07
  • Your plan of correction goes in your facility file, which the public can see. Families looking for care may read how you handled a problem.▶ 00:02:26
  • The session was for all facility types and based on best practices.▶ 00:00:14
  • The presenters shared a link to the regulations on plans of correction for each facility type.▶ 00:03:16
What a plan of correction is and who writes it
  • A plan of correction is the action a provider must take after being cited for a deficiency; it says how you will fix the problem.▶ 00:04:02
  • You write the plan with your LPA's support. The LPA doesn't write it alone, except in cases like a background check violation that requires removing an employee.▶ 00:04:40
Four elements of an effective plan
  • Meaningful: it says what you'll do to fix the problem and stop it happening again.▶ 00:05:07
  • Measurable: the LPA can see how you'll reach compliance.▶ 00:05:25
  • Verifiable: the analyst lists how you can submit proof.▶ 00:05:41
  • Time-sensitive: it has a date for the fix. Submit your evidence by that date.▶ 00:05:51
  • Ask yourself whether the plan can also train your staff, and work with your LPA when a plan is hard to meet.▶ 00:06:42
Example: a broken floor tile
  • In the example, the administrator fixed a broken kitchen tile during the LPA's visit, planned to replace the floor within two weeks, and would send an invoice or photos by the due date. It fixed the risk right away and added a long-term fix.▶ 00:07:38
Correction due dates
  • Best practice is to correct deficiencies as soon as reasonably possible.▶ 00:08:28
  • The presenter said immediate health and safety risks, or cases with civil penalties, must be corrected immediately or within 24 hours, depending on the risk.▶ 00:08:45
  • The presenter said due dates are generally between 10 days and 30 calendar days after the notice of deficiency is served.▶ 00:09:02
  • Type A deficiencies (immediate risk) need immediate action. Type B deficiencies (potential risk) may get more time.▶ 00:09:16
Asking for an extension
  • Ask in writing, by mail or email, to the regional office or LPA before the due date. The presenter also mentioned 10 working days from receiving the notice.▶ 00:10:05
  • Include your reasons and show you made every reasonable effort to correct the deficiency.▶ 00:10:19
  • Extensions are up to the Licensing Program Manager, and sometimes one can't be granted.▶ 00:10:34
  • For a Type A deficiency, licensing first checks that the immediate risk is gone. For Type B, the presenter said up to 30 more days may be approved if you show the fix is under way.▶ 00:12:45
If you miss a due date
  • A missed due date can go on your facility record. Licensing may visit to discuss it, cite you again if it's still not fixed, and assess civil penalties.▶ 00:11:51
Proof of correction
  • Proof of correction is the agreed-upon evidence the LPA will accept to verify the deficiency was fixed.▶ 00:13:54
  • It can be checked by a facility visit, an office meeting, evidence sent by mail, delivery or email, or evidence dropped off in person. Your compliance history helps decide which.▶ 00:14:31
  • All proof must be in by the agreed due date.▶ 00:16:05
Self-certification
  • In some cases you can certify, under penalty of perjury, that you made the correction, on a proof-of-correction form (heard as LIC 9098 or LIC 998 in the captions; ask your LPA for it).▶ 00:16:39
  • The LPA considers your history of substantial compliance and whether other evidence exists. The form is given at the exit conference only when self-certification is acceptable, and it's decided case by case.▶ 00:16:55
Clearing the deficiency
  • If your plan and proof are satisfactory, you get a clear deficiency letter. If not, licensing asks for more or visits again.▶ 00:18:02
  • All plans of correction must be cleared.▶ 00:18:34
  • The presenter said a deficiency repeated within a year brings a civil penalty that keeps adding up until it is corrected.▶ 00:19:13
Plans of correction and appeals
  • You are encouraged to follow through on your plan of correction even if you appeal; it stays in effect unless licensing tells you otherwise in writing.▶ 00:19:59
  • Your appeal rights, and the deadline to appeal, are explained in the notice you get with the citation; follow that notice. The presenter mentioned 15 business days from the penalty or report assessment (as heard in automatic captions; not confirmed).▶ 00:20:19
  • If the appeal goes your way, you'll be notified and the action closed.▶ 00:20:38
Questions and contacts
  • Child care providers can email the Child Care Technical Support Program, or contact their regional office or LPA.▶ 00:22:08

Links and what’s next

Where this comes from

Written from the sources below. It is not an official record of any agency, host or presenter. Links like ▶ 00:41:10 jump to that moment in the recording. ✓ checked means an official source confirms it; ⚠ check means an official source seems to say something different. Everything else is as the presenter said it.

Every fact and its source (54, 0 checked)
What was saidWhenChecked?
The presenter said the presentation can be used by providers of all facility types.
this presentation can be used by providers of all facility types		▶ 00:00:14as said Something wrong?
The presenter said the presentation is based on best practices.
this presentation is best is based on best practices		▶ 00:00:48as said Something wrong?
The Community Care Licensing Division's mission is to promote the health, safety and quality of life of each person in community care.
the community care licensing division's CLD mission is to promote the health safety and quality of life of each person in Community Care		▶ 00:01:07as said Something wrong?
The presenter said plans of correction are required as part of the regulatory compliance process.
plan of Corrections are required as a part of the Regulatory Compliance process		▶ 00:02:07as said Something wrong?
The presenter said a plan of correction is part of the facility file, which is available to the public.
the plan of Correction is part of the facilities file which is available to the public		▶ 00:02:26as said Something wrong?
The presenter said parents or family members looking to place a child may review a facility's record.
parents or family members that are looking to place their child or a relative May review your record		▶ 00:02:45as said Something wrong?
A plan of correction (POC) is an action that must be taken after a provider has been issued a citation for a deficiency.
a plan of Correction also known as PO is an action that must be taken after a provider has been issued a citation for a deficiency		▶ 00:04:02as said Something wrong?
The provider develops the POC with the support of the Licensing Program Analyst (LPA); the LPA does not develop it alone.
the provider develops the POC with the support of an LPA an LPA does not develop the POC alone		▶ 00:04:36as said Something wrong?
The presenter said an exception may be a criminal background check violation that requires removing an employee.
such as when a deficiency is related to a criminal background check violation requiring the removal of an employee		▶ 00:04:48as said Something wrong?
The presenter named four elements of an effective POC, starting with meaningful: it outlines actions to correct the deficiency and prevent it recurring.
so what are the four elements of an effective POC a POC should be meaningful ask yourself does the POC outline what actions will be taken to correct the deficiency and prevent it from reoccurring		▶ 00:05:07as said Something wrong?
A POC should be measurable: the LPA must be able to determine how the provider will attain compliance.
a POC should be measurable the L PA must be able to determine how the provider will attain compliance		▶ 00:05:25as said Something wrong?
A POC should be verifiable: the analyst lists the methods by which proof of correction can be submitted.
should be verifiable meaning the analyst will list the methods by which the proof of Correction can be submitted		▶ 00:05:41as said Something wrong?
A POC should be time-sensitive, giving a time frame for when the deficiency will be corrected.
a PO should include the element of time sensitivity this provides a Time time frame for when the deficiency will be corrected		▶ 00:05:51as said Something wrong?
The presenter said to submit evidence by the identified due date to remain in compliance.
it is important to submit the evidence by the identified due date to remain within compliance		▶ 00:06:01as said Something wrong?
The presenter suggested asking whether the POC is a training opportunity for facility staff.
is this a training opportunity for facility staff		▶ 00:06:42as said Something wrong?
The presenter said to work with your LPA when you have challenges with POCs and other regulatory issues.
work with your LPA when you have challenges with poc's and other regulatory issues		▶ 00:07:00as said Something wrong?
Example: after a broken kitchen tile was cited, the administrator fixed the tile during the LPA's visit, planned to replace the floor within two weeks, and would submit an invoice or pictures by the POC due date.
the administrator fixed the broken tile during the lpa's visit and will replace the floor within two weeks a copy of the invoice or pictures will be submitted to the regional office or LPA by the POC due date		▶ 00:07:35as said Something wrong?
The presenter said best practice is to correct deficiencies as soon as reasonably possible.
the best practice is to correct deficiencies as soon as reasonably possible		▶ 00:08:25as said Something wrong?
The presenter said that if CCL assesses civil penalties or the issue is an immediate risk to health and safety, CCL requires correction immediately or within 24 hours, depending on the risk.
if CCL assesses civil penalties or if the issue is an immediate risk to the health and safety of the child youth client or resident in care CCL shall require the deficiency to be corrected immediately or within 24 hours depending on the immediate risk		▶ 00:08:31as said Something wrong?
The presenter said achievable POC due dates are generally between 10 days and no more than 30 calendar days after service of the notice of deficiency.
achievable and appropriate P due dates are between 10 days and no more than 30 calendar days following service of the notice of deficiency		▶ 00:09:02as said Something wrong?
Type A deficiencies require immediate action because they are an immediate risk to health and safety.
type A deficiencies will require immediate action as deficiencies are seen as an immediate risk to the health and safety		▶ 00:09:16as said Something wrong?
Type B deficiencies are a potential risk, so more time may be given to correct them.
type B are seen as a potential risk so more time may be provided to correct the deficiency		▶ 00:09:30as said Something wrong?
The presenter said an extension request must be in writing, by postal mail or email, to the regional office or LPA before the POC due date or within 10 working days of receiving the POC notice.
you must submit in writing by postal mail or email before the POC due date or within 10 working days of receipt of the POC notice to the RO or LPA		▶ 00:10:05as said Something wrong?
An extension request should include the reasons you need the extension.
include reasons as to why you need the extension		▶ 00:10:19as said Something wrong?
You should be able to show all reasonable efforts were made to correct the deficiencies.
be able to demonstrate all reasonable efforts were made to correct identified deficiencies		▶ 00:10:25as said Something wrong?
Extensions are granted at the discretion of the Licensing Program Manager (LPM).
extensions are granted at the discretion of the licensing program manager or LPM		▶ 00:10:34as said Something wrong?
The presenter said there may be times when an extension cannot be granted.
there may be occasions when it's just not possible to Grant an extension		▶ 00:10:52as said Something wrong?
The presenter said missing POC due dates can become part of the facility record.
failure to meet po due dates that can become part of your facility record		▶ 00:11:51as said Something wrong?
The regional office or LPA may visit the facility to discuss the POC and the missed due date.
the RO or LPA May conduct a facility visit to discuss the POC and Miss due date		▶ 00:11:54as said Something wrong?
If the deficiency has not been corrected, the LPA will cite again.
if the deficiency has not been corrected the LPA will site again		▶ 00:12:00as said Something wrong?
The regional office or LPA may assess civil penalties for a missed POC due date.
the RO or LPA May assess civil penalties		▶ 00:12:08as said Something wrong?
For a Type A deficiency, the regional office or LPA checks that the immediate risk has been resolved before considering an extension.
for an extension of a type A deficiency the RO or LPA will evaluate if the immediate risk to Residents children or clients in care has been resolved		▶ 00:12:45as said Something wrong?
The presenter said that for a Type B deficiency the regional office or LPA may approve an extension of up to 30 days.
for an extension of a type B deficiency the RO or LPA May approve up to 30 days		▶ 00:12:58as said Something wrong?
Proof of correction means agreed-upon evidence from the provider that the LPA will accept as verification the deficiency was corrected.
proof of Correction means agreed upon evidence submitted by the provider that the LPA will accept as verification		▶ 00:13:54as said Something wrong?
Verification methods listed included a facility inspection, an office meeting with the LPA, evidence by mail or delivery service (receipts, photos), physical drop-off of evidence, or evidence by email.
one a plan of Correction Facility inspection by the LPA two an office meeting with the LPA where evidence is prevented I'm sorry is presented by the provider three submitting evidence by mail or delivery service which can include receipts photos Etc four physical drop off of agreed upon evidence or five submitting evidence by email		▶ 00:14:31as said Something wrong?
A facility's history of compliance can be used to decide which verification method is used.
a facility's history of comp compliance can be used to determine which method will be used		▶ 00:15:09as said Something wrong?
Proof of correction must be submitted by the agreed-upon POC due date.
must be submitted by the agreed upon PLC due date		▶ 00:16:10as said Something wrong?
The proof of correction form for self-certification was captioned as LIC 9098.
self-certification using the approval correction form LIC 9098		▶ 00:16:22as said Something wrong?
With self-certification, the provider certifies under penalty of perjury that a correction has been completed (the form number was also captioned as LIC 998).
certify under penalty of perjury that a correction has been completed using the form LIC 998		▶ 00:16:43as said Something wrong?
Before allowing self-certification, the LPA considers whether the facility has a history of substantial compliance and whether no other verifiable evidence could be submitted.
does the facility have a history of substantial compliance is there no other verif verifiable evidence that could be submitted		▶ 00:16:55as said Something wrong?
The regional office or LPA may provide the self-certification form during the exit conference only when self-certification is acceptable.
May provide the LC 9098 during the exit conference only when self-certification is an acceptable means of demonstrating compliance		▶ 00:17:07as said Something wrong?
Self-certification is evaluated case by case.
self-certification is evaluated on a case-by Case basis		▶ 00:17:21as said Something wrong?
If the plan and proof are satisfactory, you receive a clear deficiency letter saying the issues have been corrected.
then you will receive a clear deficiency letter identifying that the non-compliant issues have been corrected		▶ 00:18:02as said Something wrong?
If the proof is insufficient, the regional office or LPA will ask for more information or make a follow-up visit.
the RO or LPA will request additional information or conduct a followup visit to the facility		▶ 00:18:13as said Something wrong?
All POCs must be cleared.
all poc's must be cleared		▶ 00:18:34as said Something wrong?
The presenter said deficiencies repeated within a year require a civil penalty assessment, with penalties accumulating until the deficiency is corrected.
deficiencies that are repeated within a year will require civil penalty assessment and the addition of accumulating penalties until the deficiency has been corrected		▶ 00:19:13as said Something wrong?
Providers are encouraged to complete the plan of correction even if they wish to appeal.
providers are encouraged to follow through with the completion of a plan of Correction even though you may wish to appeal		▶ 00:19:59as said Something wrong?
The POC stays in effect until the regional office or LPA gives written notice otherwise.
is deemed in effect until the regional office or the licensing program analyst provides written notice of contrary		▶ 00:20:05as said Something wrong?
The presenter said to review the appeal rights given with a deficiency, which explain the process and timelines.
review the appeal rights when being issued a deficiency as it explains the due process and line and timelines to submit Appeals		▶ 00:20:19as said Something wrong?
The presenter said an appeal must be made within 15 business days of the penalty or report assessment (as captioned).
if or when you appeal it must be 15 business days from the day of the penalty or pen or report assessment		▶ 00:20:29as said Something wrong?
If the appeal is decided in your favor, you will be notified and the action closed.
should the appeal be decided in your favor you will be notified and the action will be closed		▶ 00:20:38as said Something wrong?
Questions about child care facilities can go to the Child Care Technical Support Program by email (address garbled in the captions).
you can email the tsp team at Childcare technical support at		▶ 00:22:08as said Something wrong?
If a question isn't answered, contact your local regional office or Licensing Program Analyst.
please reach out to your local regional office or your licensing program analyst		▶ 00:22:51as said Something wrong?
The presenter pointed providers to a link to the regulations on plans of correction for their facility type.
provide folks with a link to regulations so you can explore your regulations about plans of Corrections specific to your facility		▶ 00:03:13as said Something wrong?