remediation-plan

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					                                                                                                PLAN OF REMEDIATION                                                                                              ]




Area Signature, Title & Date POR Submitted and Approved                                 Provider Signature, Title and Date all Remediation   Area Signature, Title & Date all Remediation Complete and Verified by
                                                                                        Complete and Presented to Area                       Area

Provider Name:                                                                          Provider Number:                                     Tracking Number(s):                  Page Number:
                           Programmatic
(sequential)

Action Item



               Discovery
  Number




                                            QIO Deficiency
                 Type


                               Item



                                                            Description of Deficiency                                         Accountable      Start                   Date
                               QIO

                                          Number Related to                               Corrective Action Required                                   Due Date                        Evidence of Completion
                                                                   or Citation                                                 Person(s)       Date                  Complete
                                          Programmatic Item




                                                                                                                                                   C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
                                                                                               PLAN OF REMEDIATION                                                                                     ]



Provider Name:                                                                          Provider Number:                            Tracking Number(s):                 Page Number:




                           Programmatic
(sequential)

Action Item



               Discovery
  Number




                                            QIO Deficiency
                 Type


                               Item
                                                            Description of Deficiency                                 Accountable     Start                  Date


                               QIO
                                          Number Related to                              Corrective Action Required                           Due Date                       Evidence of Completion
                                                                   or Citation                                         Person(s)      Date                 Complete
                                          Programmatic Item




                                                                                                                                         C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
                                                                                               PLAN OF REMEDIATION                                                                                     ]




Provider Name:                                                                          Provider Number:                            Tracking Number(s):                 Page Number:
                           Programmatic
(sequential)

Action Item



               Discovery
  Number




                                            QIO Deficiency
                 Type


                               Item




                                                            Description of Deficiency                                 Accountable     Start                  Date
                               QIO




                                          Number Related to                              Corrective Action Required                           Due Date                       Evidence of Completion
                                                                   or Citation                                         Person(s)      Date                 Complete
                                          Programmatic Item




                                                                                                                                         C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
PLAN OF REMEDIATION                                                                 ]




                      C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
PLAN OF REMEDIATION                                                                 ]




                      C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
PLAN OF REMEDIATION                                                                 ]




                      C:\Docstoc\Working\pdf\fc9d8514-b2c9-45e2-bd58-8086de921de0.xls
Administrative                QIO Alert            QIO Alert
Adult Day Training            QIO Deficiency       QIO Report
Behavior Analysis Services    APD Deficiency       Area Monitoring
Behavior Assistant Services   External Discovery   Medicaid Integrity
Companion Services                                 Medicaid Fraud
In-home Support Services                           Abuse/Neglect
Personal Care Assistance                           Incident Report
Residential Habilitation                           Medication Error
Respite Care                                       Death Report
Special Medical Home Care                          Restraint and Seclusion Report
Support Coordination                               Complaint
Supported Employment
Supported Living Coaching
CDC+ Consultant Tool
NA
nd Seclusion Report

				
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