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Corrective Action

Corrective actions

As a Medicaid Certified Agency and/or licensed provider, you must stay in continued compliance with all Oregon Administrative Rules (OARs) applicable to your credential.

Licensing violation or incident Plan of improvement  Other information

Licensing violation or incident

When a licensing violation is noted or an abuse investigation is substantiated, I/DD Licensing may:

  • Place conditions on, suspend or revoke certification or licensure.
  • Issue an advisory letter or civil penalty in the amount outlined in Oregon Revised Statute (ORS). Civil penalties are issued according to type of licensing infraction or incident of substantiated abuse.

Plans of improvement

A Plan of Improvement (POI) is a documented plan written by the provider that details how the provider will correct specific OAR deficiencies identified during a licensing review.

Supporting documentation may be requested to accompany the POI. When a request is made for supporting documentation, the licensor will note this under Tag 9999 on the onsite report.

The provider is given a timeline for completing the POI based on the outcome of the review. POIs are required within 30 days of the receipt of the report but can be required prior depending on the severity of the licensing issues noted (identified in the licensing letter that accompanies the licensing report).

The Plan must address each deficiency on the licensing report. An acceptable POI must include:

  • Action to be taken to correct the rule violation for individual(s) cited;
  • Action to be taken to prevent the occurrence for other individuals;
  • People responsible to ensure actions are completed;
  • Dates when correction action will be completed;
  • How the POI issues will be monitored by agency to prevent reoccurrence; and
  • Any supporting documentation requested in Tag 9999 of the onsite report.

Plans submitted that do not address all of the points identified above, or do not include the requested additional documentation, will not be accepted and will be returned to the provider for completion.

Other information


A variance is an exception to a specific requirement as described in OAR. It describes a specific alternative practice that continues to meet the individual's support needs.

Variance requests are filed using form 6001. The form is submitted directly to your local CDDP for review and approval. The CDDP will forward the signed request to the I/DD Licensing Unit for final review and approval.

A separate variance request is required for each OAR, individual and site. If an individual moves place of residence or work location, a new variance request must be filed and approved.

A copy of the current approved variance must be maintained at the site and available for review.

Capacity changes

A capacity change request is a formal request to increase or decrease the licensed capacity of a 24-hour residential site. After discussion with the local CDDP, providers complete the Change of Capacity form. The provider submits the form directly to the I/DD Licensing Unit for review and approval.

Provider payments

The I/DD Licensing Unit certifies, licenses and monitors providers. It is not involved in the provider enrollment or payment systems. All licensing activity (new entity, renewal, capacity change, closure) is reported nightly through an automated system to the eXPRS authorization and payment unit.

Providers and CDDPs experiencing authorization or payment issues are directed to contact the eXPRS system for technical assistance through the following numbers: