The remediation plan is corrective action plan developed collaboratively by the MLTC plan and the SADC. The plan must include detailed actions the SADC will take to remediate all areas of non-compliance identified during the compliance review.

All SADCs must comply with all State and Federal standards, including those found in the Centers for Medicare and Medicaid Services (CMS) HCBS Final Rule. If an SADC does not meet compliance with all standards, a plan to remediate the non-compliant issues must be developed. It is the expectation that the MLTC plan will work with the SADC to develop an acceptable remediation plan, to ensure remediation activities are completed appropriately and timely, and to provide proof of remediation when requested by the Department.

The Department conducts annual reviews of SADC facilities and participant Person Centered Service Plans (PCSPs) to assess for compliance with all State and Federal requirements. If areas of non-compliance are identified during the review, the Department will send the MLTC plan that attended the review a remediation plan template to complete.

The remediation plan template is a Microsoft Excel spreadsheet pre-populated with the reviewer's compliance findings, observations (when applicable) and comments. The blank fields in the template must be completed with the specific remediation action steps, the individual responsible for implementing the actions, and the target completion date for each action.

The completed remediation plan must be submitted within two (2) weeks of the day that it was issued.

Note: It is the expectation that the MLTC plan work with the SADC to develop an acceptable remediation plan and ensure that specific remediation activities outlined in the plan are completed appropriately and timely.

The MLTC plan that attended the review must work collaboratively with the SADC to develop an acceptable remediation plan. The Department strongly encourages the MLTC plan to schedule a meeting with the SADC to review all compliance findings, discuss areas of non-compliance to determine the appropriate corrective actions that will remediate each non-compliant issue.

Completing the Remediation Plan Template

• Save a copy of the remediation plan template to a local computer.
• Maintain the original file format. Do not modify or delete any columns or rows.

Cover Page Requirements

• Complete the cover page with the following information:
  • The date the remediation plan is completed with the SADC and approved by the MLTC plan.
  • The full MLTC plan name.
  • The SADC representative's first and last name, title, phone number and email address.
  • The MLTC plan representative's first and last name, title, phone number and email address.

Remediation Plan_1 and Remediation Plan_2 tabs:

• Complete the following steps for both tabs:
• Filter the spreadsheet to view only the areas of non-compliance.
• Address each area of non-compliance with a concise action plan that contains specific and verifiable actions.
  • Use action words and future tense.
  • Do not use the remediation plan to refute the Department's findings.
• Identify the individual(s) responsible for implementing the action plan.
• Specify the target start and completion date for each action.
  • Different actions may have different target completion dates.

The Department recognizes that not all remediation actions will be completed at the time the remediation plan is submitted. However, all remediation actions must be completed within thirty (30) days of the original remediation notification.

The Reference Table tab of the remediation plan template provides examples of acceptable remediation actions and documents that may be submitted as proof of remediation. The examples provided are considered suitable actions but are not mandatory.

Notes:

• Ensure both Remediation Plan_1 and_2 tabs are completed.
• All remediation activities must be completed within thirty (30) days of the original remediation notification.

Once the remediation plan template has been populated it should be reviewed by the MLTC plan for accuracy, grammatical errors, and template format, before submitting to the Department.

The remediation plan must have:

• A detailed summary of the remediation plan which explains the activities to be implemented to become compliant with the HCBS Final Rule.
• The date the remediation activities will begin and will be completed to bring the SADC into compliance with the HCBS Final Rule.
• The person(s) responsible for implementing the plan.

Notes:

• Do not submit proof of remediation with the completed remediation plan (it is the responsibility of the MLTC plan to confirm remediation).
• Submit the remediation plan within two weeks of receipt.

Remediation Plan Accepted

If the Department determines that the actions described in the remediation plan will resolve all areas of SADC non-compliance, the Department will send an email to all MLTC plans contracted with the SADC. This notification states the Department has determined the remediation plan is acceptable and if the actions are followed, would bring the SADC into compliance. The Department will request proof of remediation within thirty days. Please see the section below for the Proof of Remediation process.

Remediation Plan Not Accepted

If the Department determines that the submitted remediation plan does not address all areas of non-compliance, the remediation plan will be deemed unacceptable and returned to the MLTC plan. The MLTC plan will have two (2) business days to revise and resubmit the remediation plan.

The returned remediation plan will include detailed comments explaining why the proposed action(s) will not result in compliance. The originally submitted remediation plan will be attached to the email and only the identified sections should be corrected. Refer to the Developing a Remediation Plan section above for additional guidance.

Correcting the Remediation Plan:

• Save the attached remediation plan to a local computer.
• The MLTC plan and SADC should review the plan together.
• Revise only the areas identified by the Department.
• Do not reformat or alter the spreadsheet.
• Resubmit the corrected remediation plan to the Department by the specified due date.

Proof of remediation refers to the evidence obtained from the MLTC plan to confirm the plan verified the activities agreed to in the remediation plan were performed, bringing the SADC into compliance.

After the remediation plan is approved by the Department, the SADC will be given time to implement the remediation actions by due date indicated on the remediation plan. Once the last date remediation will be completed has passed, a request for proof of remediation will be sent to the MLTC plan. The accepted remediation plan will be attached to the request for proof of remediation (see previous section on Remediation Plans)

The MLTC plan will be given two (2) weeks from the date of the request to submit the proof of remediation to the Department. If the proof of remediation is not received by the due date, the Department will follow-up with the plan.

Please Note: The Department will typically request proof of remediation from the MLTC plan that attended the review. However, all MLTC plans contracted with the SADC are responsible for ensuring the remediation actions are completed and for obtaining and retaining proof of remediation.

MLTC plans are expected to work with the SADC to obtain proof of remediation from the SADC as the remediation actions are completed. All remediation efforts must be completed within thirty (30) days of the original remediation notification.

Examples of acceptable proof of remediation include:

• Updated SADC policies and procedures.
• An updated SADC PCSP template.
• Evidence of resources for participants.

Notes:

• Physical alterations or modifications to the SADC facility are exempt from the 30 day timeframe.
  • Proof of remediation for these items should include a detailed plan and expected date of completion.
• Do not include any Protected Health Information (PHI) or Personal Identifiable Information (PII) in emails or submissions.

If an SADC is unable or unwilling to complete remediation activities, the SADC is considered non-compliant. SADCs must be compliant with all State and Federal requirements, as well as MLTC plan requirements, to continue providing services to MLTC plan members.

Once the MLTC plan has confirmed the SADC cannot provide proof of compliance, all MLTC plans contracted with the SADC MUST terminate the contract(s) with the SADC and notify the Department immediately. All MLTC plans contracted with the SADC will be notified by the Department via a determination letter.

Additionally, MLTC plans must:

• Assist members in transferring to a compliant SADC, or to an SADC that is in the process of remediating non-compliance.
• Remove the SADC from the network by the next quarterly Provider Network Data System (PNDS) submission.
• Notify the Department of the contract termination and reason for the termination by the due date.

MLTC plans are required to monitor continued, ongoing compliance with all State and Federal regulations.