Processes that Led to the Deficiency


The PoC should also address the processes that led up to the deficiency.


The following are examples of processes that could have led to the deficiency, failure to ensure quarterly evacuation drills:

  • New personnel were not fully trained in their duties.
  • There was no back-up plan in place for when staff, who are responsible for conducting evacuation drills, were unavailable.
  • There was no system to monitor when evacuation drills were completed