Determining the Root Cause of a Violation/Deficiency

The PoC process mandates that facilities develop and implement policies and procedures to remedy deficient practices promptly and to ensure those corrections are lasting.

Facilities must take the initiative and responsibility for monitoring their own performance to sustain compliance.

To develop the PoC, the facility must first analyze the deficient practice to determine what happened and why the problem exists or why it occurred.

When the facility understands the root cause of the deficient practice, it can develop the solutions needed to correct the problem and sustain compliance.

Deficient practice results from either system failures or discrete failures.