Example for Creating a CAP – After an unannounced inspection, Provider A receives a licensing report on August 1^st that includes the second citation for late reporting within a one-year period.

1. 1. Isn’t this supposed to be a 2 year period? Or is 1 year just as an example?

#1 conduct a RCA in accordance with the written quality improvement program, to determine the root cause of these systemic violations.

1. 1. Is this a required part of all quality improvement programs?

#2c – (also reviewed in b.) if there are policy/procedure/form changes that are required to be submitted as a part of the CAP BY THE DUE DATE, this may be impossible to meet due to the need for the Board to approve policy changes or the time it may take for forms to be updated especially as the due date is only 15 business days.