2nd Component: The Deficient Practice Statement


The deficient practice statement indicates the part of the requirement that is not met. It summarizes the issues that demonstrate the facility's actions, or failures to act, that resulted in noncompliance with the requirements.


It also includes the extent of the deficient practice. This is the number of individuals, or items, affected or potentially affected by the deficient practice.


For example:

  • 4 out of 6 individuals were affected by the deficient practice;
  • 3 out of 7 individuals with behavior intervention plans; or
  • 15 out of 47 sprinkler heads


Example of a Deficient Practice Statement

Based on observations, interviews, and record reviews, the facility failed to develop training programs for individuals who demonstrated they needed assistance in dressing themselves for 4 of 6 individuals (Individuals #1, 2, 3 and 4).