SECTION 6. CORRECTION

.01 Correction principles. Correction must be made in accordance with the following principles:

(1) Restoration of affected individuals. With respect to failures to meet the requirements of § 501(r)(4)(A), (r)(5), or (r)(6) and to the extent reasonably feasible, the hospital organization should make the correction with respect to all affected individuals and should restore any affected individual to the position in which he or she would have been had the failure not occurred, regardless of whether the harm suffered by the individual occurred in a prior year and regardless of whether such prior year is a closed taxable year. Restoration of a FAP–eligible individual who has paid more than he or she owes as a FAP–eligible individual does not require a refund if such excess payment was less than $5.

(2) Reasonable and appropriate cor- rection. The correction should be reasonable and appropriate for the failure. Depending on the nature of the failure, there may be more than one reasonable and appropriate correction.

(3) Timing. The correction should occur as promptly after discovery as is reasonable given the nature of the failure.

(4) Implementation/modification of safeguards. If the hospital organization has not established practices or procedures (formal or informal) for its hospital facility or facilities that are reasonably designed to promote and facilitate each facility’s overall compliance with the requirements of § 501(r), the hospital organization should establish such practices or procedures as part of its correction. If the hospital organization has established such practices or procedures, the hospital organization should determine if changes to its practices or procedures are needed to reduce the likelihood of that type of failure recurring and to assure prompt identification and correction of any such failures that do occur. If it identifies any such changes to its practices or procedures, it should implement those changes.

.02 Examples. The provisions of section 6.01 may be illustrated by the following examples. For purposes of these examples, assume that the hospital facility corrected the failure as promptly after discovery as is reasonable given the nature of the failure and put into place revised or newly established practices or procedures to minimize the likelihood of the failure recurring.

(1) A hospital facility has failed to adopt a CHNA report that contains all of the elements required by § 1.501(r)–3. It may correct the failure by preparing and adopting a CHNA report containing all of the required elements and making the corrected CHNA report widely available to the public within the meaning of § 1.501(r)–3(b)(7).

(2) A hospital facility has failed to adopt a FAP that contains all of the elements required by § 1.501(r)–4. It may correct the failure by establishing a FAP containing all of the required elements and widely publicizing that corrected FAP within the meaning of § 1.501(r)–4(b)(5).

(3) A hospital facility has failed to widely publicize its FAP in the manner

described in § 1.501(r)–4(b)(5) because the FAP is not available on the hospital facility’s (or any other) Web site for several months. The hospital facility may correct the failure by beginning to make the FAP widely available on a Web site as described in § 1.501(r)–1(b)(29) and doing additional public outreach to let affected individuals know the FAP is now available on the hospital facility’s Web site (for example, through an “email blast” to patients whose email addresses the hospital facility has on record).

(4) A hospital facility has failed to meet the requirements of § 1.501(r)–5 because, due to processing errors, it charged FAP–eligible individuals more than an amount permitted under that section and discovers the errors during the month-end accounting period closing. The hospital facility may correct the failure by providing all of the affected FAP–eligible individuals with an explanation of the error, a corrected billing statement, and a refund of any payments the individuals made in excess of the amounts owed after FAP discounts are applied (in cases in which the excess is $5 or more).