Frequently Asked Questions
June 30, 2023

Corrective Action Plans: Frequently Asked Questions

Corrective Action Plans: Frequently Asked Questions

Corrective Action Plans: Frequently Asked Questions

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 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.

Providers involved with developing a CAP tend to have several questions about the process. We’ve recapped a number of these questions below as a quick reference.

When is my CAP due?

The Justice Center requires that your CAP is approved by your state oversight agency (e.g. Office of Mental Health, Office for People With Developmental Disabilities) within 100 days from the date of the determination letter sent by the Justice Center. You should refer to the specific timeframes set forth by your state oversight agency or other regulatory body as they may require a different timeframe.

The Justice Center determined the case was unsubstantiated, does my agency need to submit a corrective action plan?

In short, probably! You should review the letter of determination and investigation summary report to identify areas of concern. An unsubstantiated determination by itself does not mean that corrective actions are not needed. In most cases, a corrective action plan is beneficial because it assists facilities and provider agencies in identifying ways to prevent incidents of abuse and neglect.

The Justice Center did not note any areas of concern in the investigation report, so how do I know what to put in a corrective action plan?

You should review all investigative materials to determine areas in need of improvement. Your Incident Review Committee or Special Review Committee may also make recommendations.

Why does the Justice Center follow up on my program’s corrective action plan when the state oversight agency already approved the plan?

The Justice Center has the authority and responsibility to make recommendations to improve the quality of care at facilities and provider agencies under its jurisdiction. This is done through reviews and audits of corrective action plans. This important audit function allows the Justice Center to make recommendations to facilities and provider agencies so that they can improve the quality of care and prevent incidents of abuse and neglect.

Is termination of staff considered a corrective action?

Yes, termination is considered a corrective action. However, this action alone may not be enough to prevent a similar incident from occurring and you should consider other areas in need of improvement, such as training or policy changes.

What steps should my agency take while an investigation is underway?

The most important thing to do while an investigation is underway is ensure the safety of the people in care and of staff. This often includes taking immediate steps to safeguard people, like seeking medical care and, if warranted, separating subject staff from victims, fixing any environmental issues, and providing enhanced oversight of the program. If the Justice Center or state oversight agency is conducting the investigation, you should not conduct any investigative activities, such as taking written statements and conducting interviews, unless explicitly directed to do so by the Justice Center, your state oversight agency, or as required by other regulatory bodies.

The subject is appealing the substantiated finding, should my agency wait until the appeal process is complete to develop corrective actions?

An appeal does not alleviate an agency’s requirement to complete a CAP, so you should not wait until the appeal process is complete to develop and implement corrective actions. The appeals process is a separate process from the corrective action planning process so a CAP should still be developed.

The authorized person in my agency already submitted information to the Administrative Action Reporting Mechanism (AARM). Do we still need to develop a CAP?

Yes, AARM submission and CAP development are two different processes. While the AARM requires that your agency submit information about actions taken with staff after a substantiated report of abuse or neglect, the CAP process includes a more robust review of the agency’s policies, trainings, and practices to implement corrective actions that may help prevent future incidents of abuse and neglect.

Interested in learning more? Check out our full CAP toolkit linked below. We cover FAQs, incident lifecycles, case studies and much more.