What is a Corrective Action Plan?
A Corrective Action Plan (CAP) is a document submitted to ABC that demonstrates your facility’s
compliance with one or more standards that were in question after your onsite survey.
When is a CAP required?
ABC may request a CAP for any of the following reasons:
• Your facility receives an overall failing score
• Your facility passes overall but falls below the passing threshold for a full three-year accreditation
• Your facility missed any standards that are considered mandatory, regardless of overall score. These standards are:
|AD.5, AD.6 || HR.6, HR.6.1 || PC.6.9, PC.6.9.1 || FS.3.2.2, CB.1|
|HR.4.1, HR.4.2 || HR.8.2, HR.8.3||PC.9.1, PM.10||CB.4.1|
If you receive a request from ABC for a CAP, your accreditation is not fi nal until your CAP has been approved.
If you fail to submit a CAP by the deadline, your application for accreditation will be denied and any existing
accreditation may be revoked. You will then need to submit a new application, including all fees, for an
additional onsite survey.
Is there any cost to submit a CAP?
No. However, if you are required to have an additional onsite survey, you will be notifi ed in your accreditation
decision letter. Resurveys will require additional fees.
What is the proper format for CAPs?
Address each standard marked N (Non-Compliant) or P (Partially Compliant) in the following format:
|We have now completed a yearly fi re drill. In the|
future, these will be completed on the fi rst Monday of
|A completed copy of the fi re drill report, including|
signatures of employees in attendance.
Can I just submit my entire Policies and Procedures Manual?
No. Only submit the specifi c policies and procedures that are directly relevant to the surveyor’s comments. Policy
and procedure manuals will not be accepted as a CAP.
What should be included in my CAP?
Include copies of all completed documentation showing that changes have been made. New forms, logs, training notes and annual reports must be fi lled in with the appropriate information. Meeting minutes and notes with patient-identifying information removed can also be used to support correction statements. If applicable, completed documentation should include dates, signatures and information about when the next audit/check will be performed.
Note: If a completed annual review for your facility is part of the documentation needed for your CAP, ABC asks that you go ahead and perform the review with the information you have available, even if the scheduled date for that review is after your CAP deadline. This will help ABC better evaluate your accreditation status.
DO NOT send original documents, as items submitted to ABC will not be returned.
What if my CAP is incomplete?
If ABC needs more information to make a fi nal decision, you will have one more opportunity to submit materials. You will receive a second request letter with a new deadline and details about what information is still needed.
Once complete, how do I submit my CAP?
You may mail, fax or email your CAP to:
Attn: Standards and Compliance Assistant
330 John Carlyle St, Suite 210
How will I know that you have received my CAP?
Upon receipt of your CAP, we will send you an email confi rmation. We suggest that you follow up with us if you have not received a confi rmation within one week of sending in your CAP.
What is the timeline for CAP submission and review?
CAP Submission Checklist
• Within 60 days of the date of your decision letter, you must make the required corrections for your facility
• Within 60 days of receiving your completed CAP, we will review your submission. Due to the intensive
nature and volume of CAP reviews, it takes approximately eight weeks for this process.
• If your CAP is incomplete or requires additional information, you may receive a second CAP request. At
that time, the above timeline will start over.
__ All standards marked P or N are addressed
__ Documentation is included for all standards
__ Patient names, birth dates, social security numbers, etc. are blacked out
__ All template forms and logs are completed
__ Where policies have been revised or implemented, a copy of the single policy is included
__ Facility has retained all originals and sent only copies to ABC