45 CFR § 180.80 - Corrective action plans.
(a) Material violations requiring a corrective action plan. CMS determines if a hospital's noncompliance with the requirements of this part constitutes material violation(s) requiring a corrective action plan. A material violation may include, but is not limited to, the following:
(c) Compliance with corrective action plan requests and corrective actions.
(1) A hospital required to submit a corrective action plan must do so, in the form and manner, and by the deadline, specified in the notice of violation issued by CMS to the hospital and must comply with the requirements of the corrective action plan.
(2) A hospital's corrective action plan must specify elements including, but not limited to:
(i) The corrective actions or processes the hospital will take to address the deficiency or deficiencies identified by CMS.
(ii) The timeframe by which the hospital will complete the corrective action.
(3) A corrective action plan is subject to CMS review and approval.
(d) Noncompliance with corrective action plan requests and requirements.
(1) A hospital's failure to respond to CMS' request to submit a corrective action plan includes failure to submit a corrective action plan in the form, manner, or by the deadline, specified in a notice of violation issued by CMS to the hospital.
(2) A hospital's failure to comply with the requirements of a corrective action plan includes failure to correct violation(s) within the specified timeframes.