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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 410. Regulations for the Licensure of Hospitals in Virginia
6/13/2026

12VAC5-410-150. Plan of correction.

A. Upon receipt of a written inspection report, the chief executive officer or the chief executive officer's designee shall prepare a written plan of correction addressing each licensing violation cited at the time of inspection.

B. The chief executive officer or the chief executive officer's designee shall submit to the OLC a written plan of correction no more than 15 business days after receipt of the inspection report. The plan of correction shall contain, for each licensing violation cited:

1. A description of the corrective action to be taken and the position title of the employees to implement the corrective action. If employees share the same position title, the chief executive officer or the chief executive officer's designee shall assign the employees a unique identifier to distinguish them;

2. The expected correction date, not to exceed 45 business days from the exit date of the inspection; and

3. A description of the measures implemented to prevent a recurrence of each licensing violation.

C. The chief executive officer or the chief executive officer's designee shall ensure that the person responsible for the validity of the plan of correction signs, dates, and indicates their title on the plan of correction.

D. The OLC shall notify the chief executive officer or the chief executive officer's designee, in writing, if the OLC determines any item in the plan of correction is unacceptable.

E. The OLC may conduct an inspection to verify that any portion of a plan of correction has been implemented.

F. The chief executive officer or the chief executive officer's designee shall ensure the plan of correction is implemented and monitored so that compliance is maintained.

G. The commissioner may deny licensure or renewal of licensure if the chief executive officer or the chief executive officer's designee fails to submit an acceptable plan of correction or fails to implement an acceptable plan of correction.

H. The OLC shall consider the submission date of a plan of correction to be the date the plan of correction is postmarked or the date it is received, whichever is earlier.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from VR355-33-500 § 1.15, eff. July 28, 1993; amended, Virginia Register Volume 11, Issue 8, eff. April 1, 1995; Volume 11, Issue 16, eff. June 1, 1995; Volume 23, Issue 10, eff. March 1, 2007; Volume 42, Issue 18, eff. June 4, 2026.

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