Criterion #1

The first criterion of an acceptable PoC is:

How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice.

This first criterion of an acceptable PoC needs to cover what the facility is going to do to correct the specific deficiency.

A facility's PoC should also address what processes or events led up to the deficiency. This will ensure all aspects of why the deficiency occurred are explored.

Examples:

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?

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 backup 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.