Could this happen in your program? When an incident requires corrective action

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.

Here we’re sharing a sample fictional scenario that would prompt the creation of a Corrective Action Plan.

Incident

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 that 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 what happened with the maintenance person. The admissions counselor at the hospital reported the incident to the Justice Center.

What are the main areas 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 actions to protect Jessie and other people receiving services because the allegations were not reported

What areas need 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?

What types of documentation should you maintain as supporting evidence of implementation of your corrective actions?

• Training records and Justice Center Code of Conduct forms for staff
• Incident management policy and maintenance policy; staff training on policies
• Counseling memo, re-training, disciplinary actions taken against the maintenance person and the residence counselor

Interested in learning more? Download our full toolkit outlining our guidance for Corrective Action Plans below.

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