Within sixty (60) days after a final audit report, each audited facility is required to develop and submit to NAME OF APPROPRIATE COMPANY OFFICIAL  a detailed Corrective Action Plan to address the findings noted in the audit.  The Corrective Action Plan will set forth:

1. Each deficiency that was identified by the audit;
2. The action that will be taken by the facility to correct each deficiency (collectively, the “Corrective Action Plan” and individually, “Corrective Actions”);
3. The projected completion date of each corrective action; and
4. The person responsible for each step of the Corrective Action Plan.

Within thirty (30) days of submission to NAME OR NAMES AND OR DEPARTMENTS and then the appropriate legal counsel.  If it is determined during the review process that the Corrective Action Plan as a whole, or any Corrective Action, is not appropriate, the Corrective Action Plan will be returned to the facility for review.  The facility will then be required to submit a revised Corrective Action Plan within thirty (30) days.  The review process will then be repeated for the revised Corrective Action Plan until the necessary approvals are obtained.

Each facility will be required to submit a semiannual update on the status of its Corrective Action Plan to the APPROPRIATE COMPANY OFFICIAL.  This update shall include supporting information regarding the corrective actions taken.  This information may include, as appropriate, written documentation such as; policies, procedures, training programs, training records, measurements and monitoring reports, photographs, and videotapes.

The Auditor shall review this information to determine if the Corrective Action Plan has been satisfactorily implemented.  Where appropriate, this review may involve a follow-up site visit.  When the Corrective Action Plan has been satisfactorily implemented, the Auditor shall indicate their approval on the Corrective Action Plan.

On repeat audits, Auditors may also verify that corrective actions previously taken are continually implemented to ensure that prior findings do not recur.

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