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Designing an Effective Corrective Action Plan

According to the Office of Inspector General (OIG), one of the components of an effective corporate compliance plan is "responding appropriately to detected offenses and developing corrective action." This means that an effective corporate compliance plan not only outlines compliance and practice standards but should also detail how to respond when those standards are not followed (i.e., through the implementation of corrective measures). Designing an effective corrective action plan helps healthcare organizations with this response process.

Corrective action plans are implemented as a means of facilitating the overall goal of full compliance with applicable laws and regulations, standards of conduct, and internal policies. A corrective action plan is necessary when a deficiency is identified through monitoring, auditing, or other means. It should identify the cause of non-compliance, include steps and improvements to correct the current deficiency, aim to lower the risk of the offense reoccurring, and define accountability.

Beginning with an investigation assures that the facts of the issue of non-compliance are understood. Was the discovered non-compliance regulatory, environmental, equipment related, due to an outdated policy or process, or human error? Understanding the "who, what, when, how, and why" helps a healthcare provider recognize what led to the issue and what conditions existed to allow the issue to occur.

Based on the investigation results, the Compliance Officer should update or create new policies and procedures to prevent future violations of the same nature. The Compliance Officer should then collaborate with the compliance committee and administration to implement any recommended policies and procedures, additional training and education, and reporting to appropriate government agencies as they see fit. The steps and improvements should be chosen to reflect the severity of the offense. Also, Compliance Officers must determine that the corrective action plan has been implemented appropriately by defining accountability when needed. Further monitoring and auditing may be appropriate to confirm corrective actions have been effective.

HCP frequently receives questions about responding appropriately to detected offenses and what corrective action to take. Not only is it critical to respond quickly and thoroughly to detected compliance issues, but the response must also be well-documented through a corrective action plan. The appropriate response might vary based on a healthcare provider's policies and procedures and the detected offense but should always follow the same framework.

As part of HCP's Corporate Compliance Program, each client has access to compliance experts who can help them navigate the complexities of maintaining their compliance program. Clients can discuss the importance of monitoring, auditing, and implementing corrective action plans with our compliance experts during their Corporate Compliance Assessment review.

If you have questions about implementing a corrective action plan, please reach out to your HCP Support Team. We can provide you with a Sample Corrective Action Plan to assist you with this process.

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