Developing a successful PoC involves more than just reading a deficiency and developing a plan to correct it.

It requires the provider to analyze the statement of deficiencies or violations and determine the underlying problem that generated the deficiency or violation.

An agency achieves and maintains compliance when systems are in place for each type of service and when the agency consistently monitors its practices and makes adjustments as necessary.

When a system or part of the system isn't working, it is the agency's responsibility to recognize and correct the problem, preferably before the surveyor identifies a deficient practice.

When a violation or deficiency is identified and cited, the agency is required to correct the identified violation or deficiency and ensure that it does not recur.