Free Form 02AG048E - Oklahoma

*02AG048E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Notice to Comply
Date of notice:

OKDHS finding
OKDHS has determined that your agency has violated recruitment rules in accordance with the ADvantage program Conditions of Provider Participation (CoPP).

OKDHS/Aging Services Division (ASD) review team representative

Phone number

Plan of correction
Describe in detail steps your agency will take to prevent further recruitment violations of CoPP. Attach additional pages if necessary.

Provider agency name

Phone number

Signature of agency owner or administrator Issued 5-1-2009 02AG048E

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02AG048E Purpose of form

Notice to Comply

This form is used to notify an ADvantage provider agency of a violation of recruitment rules in accordance with the ADvantage program CoPP and to allow the provider to document a plan of correction. This form is used when there is a serious substantiated complaint. Instructions OKDHS finding: OKDHS ASD completes this section documenting the nature and specific details of the violation. Plan of correction: The ADvantage provider agency owner or administrator completes this section documenting a plan of correction to ensure the violation(s) is corrected. Each violation(s) must be addressed in the plan. A plan must include: · · · the specific steps to be, or that have been taken to correct the violation(s); the date the violation(s) will be, or has been corrected; and the steps to be taken to maintain compliance. Routing Original to OKDHS Aging Services Division, 2401 NW 23rd Street, Suite 40, Oklahoma City, OK 73107 Deadline This form must be returned to OKDHS/ASD within 14 business days of the OKDHS date of notice on the front of this form.

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Issued 5-1-2009