| name | deficiency-corrective-action-plan |
| title | Corrective Action Plan (Healthcare) |
| description | Drafts U.S. healthcare corrective action plans (CAPs / plans of correction) responding to survey deficiencies, audits, or inspections. Produces deficiency statements, root cause analysis, corrective actions, accountability assignments, timelines, monitoring, and validation aligned to CMS, Joint Commission, and state health department standards. Triggers on CAP, plan of correction, statement of deficiencies, survey findings, accreditation response, regulatory remediation, QAPI corrective action. |
| author | CaseMark |
| author_url | https://github.com/CaseMark/skills/tree/main/skills/legal/deficiency-corrective-action-plan |
| license | Apache-2.0 |
| version | 0.1.0 |
| execution_mode | open |
| jurisdiction | us |
| practice | healthcare |
| language | en |
| tags | ["drafting","policy","checklist","regulatory"] |
Corrective Action Plan (Healthcare)
Produces a regulator-ready CAP that is specific, measurable, and mapped to cited healthcare compliance deficiencies.
Quick Start
- Collect the survey report with citations, scope/severity, and dates.
- Run root cause analysis (Five Whys or fishbone) for each deficiency.
- Draft corrective actions (immediate + systemic) with absolute dates, owners, and monitoring metrics.
- Complete the submission checklist and obtain executive signatures.
Prerequisites
- Statement of deficiencies / survey report — citations, scope/severity, dates, cited evidence.
- Prior regulator correspondence, exit interview notes, prior plans of correction.
- Relevant policies, procedures, training curricula, competency records.
- RCA inputs — incident reports, audit data, QA/QAPI logs, staffing metrics, workflow artifacts.
- Org chart with role owners for each corrective action.
- Submission deadline and format requirements from regulator/accreditor.
Output Structure
1. Document Header
Facility name, survey/audit date(s), regulator/accreditor, CAP version/date, primary contact, submission deadline.
2. Deficiency Summary
One row per cited deficiency. Use verbatim finding text from the survey report.
| Deficiency ID | Citation/Standard | Survey Finding (Verbatim) | Scope/Severity | Affected Unit | Date(s) | Repeat? | Immediate Jeopardy? |
|---|
| D-1 | 42 CFR §___ / State Code ___ / JC Std ___ | | | | | Y/N | Y/N |
3. Root Cause Analysis
- Use Five Whys or fishbone for each deficiency.
- Distinguish systemic vs. isolated causes.
- Tie each cause to evidence from records.
4. Corrective Action Plan Table
One row per corrective action. Separate immediate correction from systemic prevention.
| Deficiency ID | Root Cause(s) | Immediate Correction | Systemic Prevention | Owner (Name/Title) | Resources | Start Date | Due Date | Milestones | Monitoring Metric | Frequency | Validation Criteria | Evidence |
|---|
|
