Creating an acceptable written plan of correction

The accreditation survey is done, and deficiencies were found. Now what? The requirements of writing and implementing an acceptable plan of correction or corrective action plan (CAP) is similar among most accrediting organizations (AOs). The key to an acceptable plan of correction starts with following the AO’s required elements to create clear, achievable responses with data to show the process.

If cited by The Joint Commission, health care organizations will receive the findings in the Survey Analysis for Evaluating Risk matrix. Surveyors can explain the submission process and direct facilities to information on their extranet site. To respond, facilities submit evidence of standards compliance on The Joint Commission Connect website under the “survey process” tab within 60 calendar days. Categories on the submission include “assigning accountability,” “correcting noncompliance” and “ensuring sustained compliance.” Condition-level deficiencies under deemed status result in a Medicare deficiency survey within 45 days. 

If cited by the Center for Improvement in Healthcare Quality (CIHQ), health care organizations receive the final report within 10 business days and are required to create an acceptable CAP for those deficiencies within 10 calendar days of the posting of the final report. CIHQ has electronic forms to guide the organization in writing the CAP. Usually, the completion of the CAPs implementation is required 45 calendar days from the last day of the survey for standard-level deficiencies, 30 calendar days for condition-level deficiencies, and 10 calendar days for immediate threat to health and safety deficiencies. The CAP must indicate how the correction will be integrated into the organization’s Quality Assessment & Performance Improvement program. 

If cited by DNV Healthcare USA Inc., health care organizations receive the final report within 10 days of the last date of the survey. Category 2 and Category 1 nonconformities require an acceptable CAP delivered within 10 calendar days from the date of the written final report. Key components stipulated by DNV Healthcare are to “identify the cause that led to the nonconformity” and “identify the process or system changes that will be made to ensure that the nonconformity does not recur.” 

Carefully following all components of the AO’s required elements is the key for hospitals seeking to achieve an acceptable plan of correction.

Mark Sears, SASHE, CHFM, CHSP.