Healthcare Corrective Action Plan

Drafts a regulatory-ready CAP addressing deficiencies from CMS surveys, Joint Commission findings, state inspections, or internal audits.

Prerequisites

Gather before drafting:

1. Survey/inspection report — statement of deficiencies, citations, scope/severity ratings, surveyor observations
2. Prior correspondence — exit interview notes, previous plans of correction, agency letters
3. Internal records — incident reports, training logs, staffing data, QA reports, committee minutes
4. Organizational docs — policies under review, org charts, job descriptions, budget plans

Quick Start

A CAP has four sections: