Corrective Action Plan Guidance for the Protection of People with Special Needs

The Justice Center, in collaboration with the Office for People with Developmental Disabilities, the Office of Mental Health, the Office of Children and Family Services, the Office of Addiction Services and Supports, and the State Education Department, created this toolkit to assist providers in developing and implementing corrective action plans that reduce the likelihood of similar incidents and safeguard people receiving services from abuse or neglect.

This toolkit provides frequently asked questions during the CAP and CAP audit process, checklists of questions to consider during the lifecycle of an incident, reference guides for documentation, case studies that can be used as training opportunities, quick tips, and other resources. 

A corrective action plan (CAP) is a written plan that is developed by a facility or provider agency in response to incidents reported to the Justice Center. The CAP provides the road map to improve the circumstances or conditions that contributed to the incident. The development of a CAP also provides an opportunity to look for additional areas in need of improvement at a facility or provider agency to protect people receiving services from harm.

Common types of CAPs include:

• Training
• Personnel
• Discipline
• Policy creation or revision
• Environmental modifications
• Treatment plan revisions
• Counseling/coaching
• Sanctions/fines

The Justice Center has the authority and responsibility to recommend improvements to the quality of care at facilities or provider agencies under its jurisdiction. This is done through reviews and audits of corrective action plans, which can include visits to and inspections of facilities or provider agencies. This important audit function allows the Justice Center to make recommendations to facilities and provider agencies to improve the quality of care and prevent incidents of abuse and neglect.

These case studies represent a collection of facts identified from Justice Center investigations. They are used for illustrative purposes only to aid in developing a corrective action plan.   

Jessie, an individual receiving services, informed her residence counselor that the maintenance person asked for her telephone number, told her she was pretty and asked her out to dinner.  Jessie stated she felt a little uncomfortable but did not share her phone number with the maintenance person and did not accept his invitation for dinner.  The residence counselor thought that because the maintenance person was not working directly with Jessie, she did not need to report this to anyone.  A few days later, Jessie needed a new light bulb in her bedroom, and the maintenance person said he would replace it if Jessie would share her phone number with him. Jessie gave her phone number to him and over the course of the next few weeks, he sent Jessie inappropriate pictures and requested that Jessie send him pictures.  Jessie moved out of the group home because she was afraid of the maintenance person.  Jessie stopped taking her medications and was admitted to a psychiatric unit in a hospital. Jessie told the admissions counselor at the hospital about what happened with the maintenance person.  The admissions counselor at the hospital reported the incident to the Justice Center.   

Issues of concern:

• The maintenance person requested Jessie’s phone number.
• The residence counselor did not report Jessie’s allegation to anyone.
• The agency did not take immediate action to protect Jessie and other people receiving services because the allegations were not reported.

Considerations for areas in need of corrective action:   

• How are maintenance staff informed of their role as a custodian?
• Incident management – are staff aware of the definitions of reportable incidents?
• Does the agency’s incident management policy provide clear guidance on reporting requirements?
• Agency policy – what is the agency’s policy on professional boundaries?  How are staff trained on the requirement not to pursue a personal relationship with people receiving services?
• Discipline – what follow-up happened with the residence counselor and maintenance person? Maintenance requests – how are they handled, and could that process be more formalized?

Additional case studies are available for download in the Toolkit below.