Correcting the Specific Deficiency


The PoC needs to address how the facility is going to correct the specific deficiency.


In the situation of a facility failing to ensure quarterly evacuation drills, the PoC should address the following questions:

  • What actions did the facility take to monitor that evacuation drills were being done?
  • Who was responsible for conducting the evacuation drills?
  • Do both staff and individuals participate during drills?