Regulation Services' Determination


Whether the PoC is submitted in the allotted time or not, Regulation Services will determine whether the PoC is acceptable. If the PoC is unacceptable, the facility will then have an opportunity to submit a revised PoC.


If a facility submits an unacceptable PoC, the regional survey office will contact the facility to convey the following:

  • the reason the PoC was unacceptable;
  • the title of the person responsible for implementing the corrective action; and
  • a statement that failure to submit an acceptable PoC within the specified time frame could lead to more stringent actions


Being acceptable means that the four elements are included as a part of the PoC for each deficiency.


If this requirement is not met, administrative penalties could be assessed.