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Corrective Actions

Medicaid-certified agencies and licensed providers must stay in compliance with all Oregon Administrative Rules (OARs) that apply to their credentials.

Licensing violation or incident  Plan of improvement


Licensing violation or incident

When ODDS Licensing notes a licensing violation or substantiates an abuse investigation, we may:

  • Place conditions on, suspend or revoke your certification or licensure.
  • Issue an advisory letter or civil penalty in the amount outlined in Oregon Revised Statute (ORS). We issue civil penalties based on the type of infraction or type of abuse.

Plans of improvement

We conduct regular licensing reviews of providers. If we identify OAR deficiencies during a review, we will let you know in our licensing report. You, the provider, must create a Plan of Improvement (POI). 

This plan shows how you will correct the deficiencies. We may ask for supporting documentation for your POI. We will note this under Tag 9999 on the onsite report.

We will give you a timeline to complete the POI based on the outcome of your review. You typically have 30 days to submit a POI after you receive our licensing report. If the licensing issues are severe, your POI deadline could be sooner. We will define this timeline in your report's licensing letter.

Your plan must address each deficiency. An acceptable plan must include:

  • Actions to correct each violation
  • Actions to prevent the occurrence for other individuals
  • People responsible to ensure actions are completed
  • Dates you will complete the above actions
  • Plans to monitor POI issues and prevent reoccurrence
  • Supporting documents requested in Tag 9999 of the onsite report

We will not accept plans that don't address all of these points or lack requested documents. We will return these plans to you for completion.