2nd Element: Procedure for Implementing the Plan of Correction


The second element of an acceptable PoC is, "The procedure for implementing the acceptable PoC for the specific deficiency cited."


The facility first identifies the specific deficiency and what led up to the deficiency being cited.


Then, the facility must explain how their PoC will be implemented for the specific deficiency.


To meet the requirements of this second element, facilities must:

  • describe the process to implement the PoC;
  • break down the steps needed; and
  • ensure the PoC will correct the deficient practice.


Using the last example, say the facility's PoC included implementing a new system for obtaining written consent for psychotropic medications.


The PoC would need to detail how this new system would work, and how the facility would coordinate the use of this new system.