answering a state monitoring review

The situation

An unannounced state monitoring visit found staffing gaps. The facility had to answer with a formal Plan of Correction.

What I changed

• Traced each staffing and compliance gap back to its root cause.
• Wrote the formal Plan of Correction, with an owner and a deadline for every corrective action.
• Made the staffing corrections and documented the evidence for each one.
• Put monitoring tools in place to catch the same problems before the next visit.

Outcome

The corrective actions in the Plan of Correction were carried out and documented, and the facility had monitoring tools in place to prevent repeat findings.