2021-02 - Recommendation 11

Develop written standard operating procedures for the specific procedures it requires Commission OCD staff to perform when conducting an NPA compliance visit including the documentation requirements and reporting to PLIMS (Finding 4B). The procedures should also include the following related to joint visits with the CNA:
a. The rationale and factors to be considered in making the decision to conduct a joint visit with the CNA versus a stand-alone visit to the NPA as well as the scope of the review.
b. Develop a protocol for communicating the roles and responsibilities of the Commission and CNA reviewers to the NPA including the scope of the Commission’s review and coordination with the CNA.
c. Determine the format of the Commission reviewer’s separate written documentation of procedures he/she performed and results, including findings requiring corrective action by the NPA. This should include timely transmission of this documentation to the CNA for submission with the CNA’s CVR transaction to PLIMS and the process to ensure the CNA tracks and closes-out any required corrective actions.
d. Determine whether to implement a formal appeals process that would be available to NPAs to assist in resolving disputes with Commission findings.