Corrective Action Plan by 991Il2

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									   BQM-006
   02/12                                      Illinois Department of Human Services
                                              Division of Developmental Disabilities
                                                       Corrective Action Plan
                                                                                                                                          Page __ of __


Provider Name: __________________________________________________________ Review Date(s): _____________________

Provider Address: ________________________________________________________ Phone:_____________________________

Provider Contact Name / Title: _______________________________________________ Email:_____________________________

Type of Review: ___Rule 116 ___CILA ___ Service Facilitation ___ Developmental Training ____ Child Group Home


   1                      2      Corrective Action                    3 Quality Assurance                   4 Name and Title               5 Target Date
                          Corrective action must include:             and Monitoring                        of Responsible                 for
                          * Steps to correct the specific concerns    Include steps to monitor status and
             Finding      identified by reviewers;                                                          Person                         Completion
                                                                      prevent recurrence of similar         Ensure each corrective         If multiple actions are
                          * Steps to identify and correct similar     problems in the future.                                              associated with a finding,
                          issues which may be present within the                                            action step in column 2 has    list target date for each
                                                                      Each corrective action step in        the name and title of the
                          agency but not specifically identified by                                                                        action. All corrective action
                                                                      column 2 must have corresponding      person responsible for         (listed in column 2) must
                          the reviewers.                              quality assurance/monitoring                                         be completed within 60
                                                                                                            coordinating corrective
                                                                      activity listed in this column.                                      days of the review exit
                                                                                                            action and monitoring for      unless an extension is
                                                                                                            quality assurance.             granted by BQM. (See exit
                                                                                                                                           letter for details.)
BQM-006
02/12                                   Illinois Department of Human Services
                                        Division of Developmental Disabilities
                                                 Corrective Action Plan
                                                                                                                                    Page __ of __

1                   2      Corrective Action                    3 Quality Assurance                   4 Name and Title               5 Target Date
                    Corrective action must include:             and Monitoring                        of Responsible                 for
                    * Steps to correct the specific concerns    Include steps to monitor status and
          Finding   identified by reviewers;                                                          Person                         Completion
                                                                prevent recurrence of similar         Ensure each corrective         If multiple actions are
                    * Steps to identify and correct similar     problems in the future.                                              associated with a finding,
                    issues which may be present within the                                            action step in column 2 has    list target date for each
                                                                Each corrective action step in        the name and title of the
                    agency but not specifically identified by                                                                        action. All corrective action
                                                                column 2 must have corresponding      person responsible for         (listed in column 2) must
                    the reviewers.                              quality assurance/monitoring                                         be completed within 60
                                                                                                      coordinating corrective
                                                                activity listed in this column.                                      days of the review exit
                                                                                                      action and monitoring for      unless an extension is
                                                                                                      quality assurance.             granted by BQM. (See exit
                                                                                                                                     letter for details.)
BQM-006
02/12                                       Illinois Department of Human Services
                                            Division of Developmental Disabilities
                                                     Corrective Action Plan
                                                                                                                                        Page __ of __

1                       2       Corrective Action                   3 Quality Assurance                   4 Name and Title               5 Target Date
                        Corrective action must include:             and Monitoring                        of Responsible                 for
                        * Steps to correct the specific concerns    Include steps to monitor status and
          Finding       identified by reviewers;                                                          Person                         Completion
                                                                    prevent recurrence of similar         Ensure each corrective         If multiple actions are
                        * Steps to identify and correct similar     problems in the future.                                              associated with a finding,
                        issues which may be present within the                                            action step in column 2 has    list target date for each
                                                                    Each corrective action step in        the name and title of the
                        agency but not specifically identified by                                                                        action. All corrective action
                                                                    column 2 must have corresponding      person responsible for         (listed in column 2) must
                        the reviewers.                              quality assurance/monitoring                                         be completed within 60
                                                                                                          coordinating corrective
                                                                    activity listed in this column.                                      days of the review exit
                                                                                                          action and monitoring for      unless an extension is
                                                                                                          quality assurance.             granted by BQM. (See exit
                                                                                                                                         letter for details.)




Corrective Action Plan
Submitted by____________________________________________ Title______________________________ Date______________
                    Signature

								
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