Except for family child care settings and foster care for children in the license holder's residence, license holders serving children shall:
(1) establish and maintain policies and procedures to ensure that an internal review is completed and that corrective action is taken if necessary to protect the health and safety of children in care when the facility has reason to know that an internal or external report of alleged or suspected maltreatment has been made. The review must include an evaluation of whether:
(i) related policies and procedures were followed;
(ii) the policies and procedures were adequate;
(iii) there is a need for additional staff training;
(iv) the reported event is similar to past events with the children or the services involved; and
(v) there is a need for corrective action by the license holder to protect the health and safety of children in care.
Based on the results of this review, the license holder must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or the license holder, if any;
(2) identify the primary and secondary person or position who will ensure that, when required, internal reviews are completed. The secondary person shall be involved when there is reason to believe that the primary person was involved in the alleged or suspected maltreatment; and
(3) document that the internal review has been completed and provide documentation showing the review was completed to the commissioner upon the commissioner's request. The documentation provided to the commissioner by the license holder may consist of a completed checklist that verifies completion of each of the requirements of the review.