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To ensure compliance with regulations, site monitoring and administrative reviews
The administrative review process reviews documentation of all required records, and
Audits are required but not part of the oversight processes used to determine compliance.
Submitting documentation that was missing during the administrative review after the fact does not show corrective action.
All administrative reviews and site monitoring are announced to help sites and sponsors prepare and review documentation for compliance.
Sponsoring organizations with multiple sites are required to monitor each facility three times a year and not more than six months may lapse between each monitoring visit.
There are specific hours and activities that can be counted toward the required number of monitoring hours.
Non-compliance with one or more of the performance standards and violation of regulations jeopardizes continued participation.
Before issuing the Notice of Serious Deficiency, the state agency considers
An example of a Serious Deficiency is
The Notice of Serious Deficiency will fully describe the problem(s), the person responsible for creating the problem, what steps that must be taken to fix the problem, and
If the corrective action resolves the Serious Deficiency, the state agency
If termination is proposed, the Sponsor
If an independent hearing officer upholds the state agency’s decision to terminate