The example continues.

The agency's PoC was:

The administrator will review all employee files to ensure that there are no further discrepancies. As new staff are hired, the administrator will conduct required criminal history checks within 72 hours. The QA/PI Committee will review employee files annually to verify this has been done. This procedure will be implemented by 7/31/19.

What makes this PoC unacceptable?

• While the plan does state who is responsible for implementing the plan, it does not address ongoing monitoring.
• The QA/PI Committee's annual review does not constitute ongoing monitoring.
• No plan is set into place to ensure that the required checks are performed, only to catch when it wasn't done after the fact.
• Z194 constitutes a Severity Level B violation, which means it must be corrected within either two or seven days after the receipt of the official written notice of the violation (depending on whether it results in serious harm to or death of a client or constitutes a serious threat to the health or safety of a client).

Did you identify any other problems with this PoC?