The second required element is the agency's plan for correcting the specific deficiency or violation cited. The plan must address the process leading to the deficiency or violation and include a monitoring procedure for ensuring ongoing compliance.

The plan should not address the specific examples cited in the deficiency or violation.

Example: Given a deficient practice regarding staff failure to follow universal precautions, an example of a part of the agency's plan of correction that addresses this element would be:

• Staff are required to wear disposable gloves while providing treatments, wound care, incontinent care, and bathing. After providing care to each patient, a staff person is required to thoroughly wash his or her hands. The supervising nurse will randomly observe 20% of staff as they perform these patient care activities to determine whether agency infection control policies have been followed.