Corrective action plan guidance: A basic overview
Investigations into abuse or neglect often reveal underlying, systemic issues within an organization that should be addressed. In this case, providers under our jurisdiction will issue corrective action plans (CAP) to identify and resolve key deficiencies. Here, we are providing a brief overview of CAPs, their uses, and our unique role in auditing their execution.
What is a Corrective Action Plan?
A 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 roadmap 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:
- Policy creation or revision
- Environmental modifications
- Treatment plan revisions
What is a Corrective Action Plan Audit?
The Justice Center has the authority and responsibility to make recommendations on improving the quality of care at facilities or provider agencies under its jurisdiction. This is done through reviews and audits of corrective action plans and can include visits to and inspections of facilities or provider agencies.
The Justice Center audit process begins with a review of issues of concern revealed during the investigation and/or identified during the agency’s subsequent review of the incident, including the investigative summary report and determination letters. When the Justice Center completes the audit, a letter is sent to the facility or provider agency with audit findings and recommendations. The state agency that operates, licenses, or certifies the facility or provider agency receives a copy of the audit findings and recommendations. Facilities and provider agencies are not required to respond to the Justice Center’s audit.
What to Expect During an Audit
The Justice Center contacts facilities and provider agencies at the beginning of the audit and provides an overview of the audit process. Documents that demonstrate implementation of the CAP will be requested. The Justice Center will assess all CAP-related documentation to determine if the corrective actions were timely and sufficient. Most of this work is done by the Justice Center remotely; however, the Justice Center may visit facilities and provider agencies to complete this work.
What happens during a site visit?
Justice Center staff may conduct an announced or unannounced visit. The first step a provider agency or facility should take is to request photo identification of Justice Center staff and contact a supervisor or Administrator on Duty to alert them of the visit. The Justice Center will explain why the visit is occurring and request a tour of the program. The Justice Center will request to review certain documentation and may conduct interviews with staff and people receiving services. The visit will conclude with an exit conference where any preliminary findings of concern will be shared. Within two business days of the visit, provider agencies and facilities will receive a letter memorializing the exit conference, and the audit letter and findings will be shared upon completion.
Interested in learning more? Check out our full CAP toolkit linked below. We cover FAQs, incident lifecycles, case studies and much more.