Criterion #3

The third criterion of an acceptable PoC is:

What measures will be put into place or system changes made to ensure that the deficient practice will not recur.

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 third criterion, 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.