Proposed Plan of Correction: Acceptable Response


The facility proposes the following PoC.


Note: The third column will be filled out for you on the next slide. Try and determine why this PoC is unacceptable before continuing to the answers.


The facility will ensure that the documentation of investigation reports reflects that all injuries of unknown origin are thoroughly investigated, as evidenced by --


Required PoC Element

Facility's Response

Acceptable Response

First element, " PoC must contain the plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited."

The incomplete investigations for non-serious injuries of unknown cause have been reopened. There was not a system in place to ensure thorough investigations.

Persons responsible: the facility director and director of quality services management (QSM)


Second element, "PoC must contain the procedure for implementing the acceptable PoC for the specific deficiency cited."

The Preliminary Investigation Report for Injuries of Unknown Origin will be revised to ensure a more complete investigation and will be used when investigating non-serious injuries and injuries of unknown origin.

Unit directors (UDs), assistant unit directors (AUDs), management supervisors, campus coordinators, and the nurse manager for the facility will be in-serviced of the revision.

Persons Responsible: facility director and director of medical services.  


Third element, " PoC must contain the monitoring procedure to ensure that the PoC is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements."

The facility director will conduct a monthly meeting with UDs/AUDs to critique investigations with regard to completeness.

If an injury report with a non-serious injury of unknown cause has not been investigated within 2 working days, the safety officer will notify the appropriate UD for action. Quality assurance staff will randomly monitor investigations for completeness. Any problems will be referred to the facility director for corrective action.

Persons Responsible: facility director and director of QS


Fourth element, "PoC must contain the title of the person responsible for implementing the acceptable PoC."

The QSM will be responsible for ensuring the implementation of the PoC.



Did you identify what makes this PoC acceptable?


Go to the next slide for the answers.