| name | corrective-action-plan |
| title | Healthcare Corrective Action Plan |
| description | Drafts healthcare Corrective Action Plans (CAPs) responding to CMS survey deficiencies, Joint Commission findings, state inspection citations, or internal audit results. Structures root cause analysis, remediation steps, accountability, timelines, and monitoring. Use when drafting plans of correction, responding to immediate jeopardy findings, condition-level citations, or standard-level deficiencies. |
| author | CaseMark |
| author_url | https://github.com/CaseMark/skills/tree/main/skills/legal/corrective-action-plan |
| license | Apache-2.0 |
| version | 0.1.0 |
| execution_mode | open |
| jurisdiction | us |
| practice | healthcare |
| language | en |
| tags | ["drafting","memo","regulatory"] |
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:
- Survey/inspection report — statement of deficiencies, citations, scope/severity ratings, surveyor observations
- Prior correspondence — exit interview notes, previous plans of correction, agency letters
- Internal records — incident reports, training logs, staffing data, QA reports, committee minutes
- Organizational docs — policies under review, org charts, job descriptions, budget plans
Quick Start
A CAP has four sections:
- Deficiency Identification & Root Cause Analysis — what happened and why
- Corrective Action Implementation — specific steps, owners, dates
- Monitoring & Validation — how compliance is measured and sustained
- Authorization — signature blocks and executive approval
Core Workflow
1. Deficiency Identification & Root Cause
For each deficiency, document:
| Field | Content |
|---|
| Regulatory citation | Exact CFR, state code, or JC standard |
| Classification | Immediate jeopardy / Condition-level / Standard-level |
| Scope & severity | CMS tag number and rating |
| Surveyor findings | Verbatim from report |
| Affected areas | Units, populations, domains |
| Recurrence history | Prior citations for same/similar issue |
Root cause analysis — apply Five Whys or equivalent, addressing each layer:
- Proximate cause — what directly happened
- Process failure — what workflow allowed it
- Supervision gap — why oversight missed it
- Training deficit — staff education/competency gaps
- Systemic factor — resource, communication, policy, or QA failures
Cross-reference against incident reports, training records, staffing patterns, and prior audits. Distinguish isolated incident vs. systemic vulnerability.
