The PoC must also include the procedures for implementing the plan of correction for the specific deficiency or violation cited. A successfully implemented PoC puts into place measures or systemic changes that will ensure that the deficient practice will not recur.

The agency should consider whether it needs to develop or modify a system.

Example: The supervising nurse will record her findings [regarding staff following universal precautions] and report to the administrator weekly. The administrator will compare the reports for patterns and trends and identify staff who need further training. Staff who fail to comply after receiving additional training will receive disciplinary action. After one month, the administrator will evaluate all reports to see if the measures taken resulted in improved compliance. The plan will continue with monitoring on a monthly basis for three months, then quarterly.