The example continues.

The agency's PoC was:

Staff are required to adhere to the agency's policy regarding admission of patients and physician orders. The Alternate Administrator will review the policy with all agency RNs by 8/8/19. The agency's initial evaluation form will be modified to include a reminder to the assessing RN to verify that a plan of care and physician's orders have been received. The QA Nurse will conduct a chart audit of all client records and identify any other clients for whom an order has not been received and any identified problems will be corrected within 5 days. Each month, the QA Nurse will review a sampling of 50% of new admissions to verify that physician orders have been received and will report any problems to the Alternate Administrator for correction. The effectiveness of these measures will be evaluated by the QA/PI Committee at each meeting and modified as necessary. Correction date: 8/10/19.

What makes this PoC acceptable?

This plan is acceptable because it addresses the system, rather than the specific instance, and it includes an ongoing monitoring program to ensure compliance. All responsible staff are identified and the correction date is acceptable.

Did you identify anything else that makes this example an acceptable PoC?