{"id":1545,"date":"2026-02-19T16:49:04","date_gmt":"2026-02-19T16:49:04","guid":{"rendered":"https:\/\/dev8.quada.org\/?p=1545"},"modified":"2026-11-03T21:44:38","modified_gmt":"2026-11-03T21:44:38","slug":"from-survey-to-plan-of-correction","status":"publish","type":"post","link":"https:\/\/quada.org\/fr\/blog-posts\/from-survey-to-plan-of-correction\/","title":{"rendered":"De l'enqu\u00eate au plan de correction\u00a0: comment QUAD A soutient les derni\u00e8res \u00e9tapes de l'accr\u00e9ditation"},"content":{"rendered":"<p class=\"wp-block-paragraph\">The on-site survey is often seen as the final hurdle before accreditation. Healthcare leaders on the path to accreditation put considerable effort into making sure that their facilities are survey-ready and in compliance with&nbsp;<strong>QUAD A<\/strong>&nbsp;standards, but there\u2019s one more step that\u2019s just as important as the survey itself.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The Plan of Correction (PoC) is the critical final step between the survey and receiving accreditation. The PoC is a roadmap that facilities must put together themselves, indicating how they will address any deficiencies identified in the survey.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Putting together an effective Plan of Correction requires intention and a commitment to prioritizing patient safety. Here we\u2019ll outline the path from survey to PoC, the key elements of a successful PoC, and how your PoC can lay the groundwork for continuous improvement.<\/p>\n\n\n\n<h2 id=\"survey-outcome-determining-compliance-and-identifying-deficiencies\" class=\"wp-block-heading\">Survey Outcome: Determining Compliance and Identifying Deficiencies<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">After your survey is complete, you\u2019ll receive a determination of compliance from the&nbsp;<strong>QUAD A<\/strong>&nbsp;Central Office. The determination summarizes how well your facility complied with&nbsp;<strong>QUAD A<\/strong>&nbsp;Standards during the survey. Each standard is marked as \u201cCompliant\u201d or \u201cDeficient,\u201d with \u201cNot Applicable\u201d used for non-Medicare facilities when appropriate.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If the surveyor identified deficiencies with any standards, the report will point out the manner (seriousness) and degree (extent) of noncompliance. Each deficiency will be identified as one of the following:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Standard-level Deficiency<\/strong>&nbsp;\u2014 Indicates noncompliance with one or more of the standards that make up each condition of certification.\n<ul class=\"wp-block-list\">\n<li><em>Survey Outcome: To achieve accreditation, the facility must submit a Plan of Correction that describes how each deficiency will be mitigated.<\/em><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Condition-level Deficiency<\/strong>&nbsp;\u2014 For Medicare-participating facilities only. Indicates substantial noncompliance with Medicare Conditions for Participation.\n<ul class=\"wp-block-list\">\n<li><em>Survey Outcome: To achieve accreditation, the facility must first submit a Plan of Correction that describes how each deficiency will be mitigated.&nbsp;<strong>QUAD A<\/strong>&nbsp;will then conduct another on-site revisit to assess the correction of deficiencies.<\/em><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Immediate Jeopardy<\/strong>&nbsp;\u2014 The highest level of deficiency. Indicates that the degree and manner of the noncompliance has caused or is likely to cause significant injury, harm, or death to a patient.\n<ul class=\"wp-block-list\">\n<li><em>Survey Outcome: Accreditation will not continue unless the immediate jeopardy is removed.<\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">It\u2019s natural to feel discouraged when deficiencies within your facility are pointed out. Remember: the ultimate goal is patient safety. Putting together a Plan of Correction is a valuable opportunity for your facility to optimize processes, enhance compliance, and improve patient outcomes.<\/p>\n\n\n\n<h2 id=\"four-keys-to-a-well-executed-plan-of-correction-what,-who,-when,-how\" class=\"wp-block-heading\">Four Keys to a Well-Executed Plan of Correction: What, Who, When, How<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Once you\u2019ve received your report detailing deficiencies, your next step is to build a written Plan of Correction. Your Plan of Correction tells&nbsp;<strong>QUAD A<\/strong>&nbsp;how you intend to address each deficiency and comply with the relevant&nbsp;<strong>QUAD A<\/strong>&nbsp;Standards.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A well-executed Plan of Correction will cover four criteria for each identified deficiency: your plan for corrective actions, who is responsible for those actions, when they will be implemented, and how they will be evaluated in the long run.<\/p>\n\n\n\n<h3 id=\"1-what-will-be-done-to-correct-the-issue\" class=\"wp-block-heading\">#1:&nbsp;<strong>Quoi<\/strong>&nbsp;will be done to correct the issue?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The first step of a well-executed Plan of Correction is to plainly state what you will do to address the identified deficiency.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Be as specific as possible. If one of the deficiencies identified during your survey was improper drug storage, it\u2019s not enough to say, \u201cDrugs will be stored appropriately from now on.\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Instead, your Plan of Correction should detail:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The specific location where you intend to store drugs moving forward<\/li>\n\n\n\n<li>The conditions under which those drugs will be stored<\/li>\n\n\n\n<li>Who will have access to drugs and under what circumstances?<\/li>\n\n\n\n<li>What training will be done to put the plan into effect?<\/li>\n\n\n\n<li>What staff members (by title) will receive this training?<\/li>\n\n\n\n<li>Etc.<\/li>\n<\/ul>\n\n\n\n<h3 id=\"2-who-is-responsible-for-implementing-the-corrective-action\" class=\"wp-block-heading\">#2:&nbsp;<strong>Who<\/strong>&nbsp;is responsible for implementing the corrective action?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Outlining a corrective plan is a great first step, but accountability ensures that the idea gets put into action.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Every Plan of Correction must include the title (not the name) of the person responsible for implementing the corrective action.<\/p>\n\n\n\n<h3 id=\"3-when-will-the-action-be-completed\" class=\"wp-block-heading\">#3:&nbsp;<strong>When<\/strong>&nbsp;will the action be completed?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">You\u2019ve outlined the corrective action and identified who will implement the plan\u2014now it\u2019s time to put it on the calendar. Your Plan of Correction must list a completion date for each deficiency.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For less complex deficiencies, you may be able to complete the corrective action before submitting your Plan of Correction. In this case, list the date that the correction was completed. For example, the date that a new process was implemented to maintain facility cleanliness.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">More complicated deficiencies may require more time and planning to correct. In this case, it\u2019s okay to list a future date when the correction will be made. For example, the date that all nursing staff will complete a half-day training session.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You will be required to submit documentation proving that the corrective action was taken on the listed correction date. For example, a signed and dated document showing when a policy was approved by the Medical Director.<\/p>\n\n\n\n<h3 id=\"4-how-will-the-effectiveness-of-the-action-be-evaluated\" class=\"wp-block-heading\">#4:&nbsp;<strong>How<\/strong>&nbsp;will the effectiveness of the action be evaluated?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Your Plan of Correction is in motion, but how will you ensure that it yields the desired outcomes? Measuring the success of your corrective actions is the final key to a well-executed PoC, demonstrating whether your plan has had its intended effect, not just in the short term, but also whether it lays the foundation for long-term improvement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">These two tips can form the backbone of your evaluation:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Identify metrics for success<\/strong>\n<ul class=\"wp-block-list\">\n<li>What metrics can you track that will demonstrate your commitment to ongoing improvement?<\/li>\n\n\n\n<li>Will these metrics be monitored through a score sheet, a review form, a dashboard, etc.?<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Establish regular monitoring<\/strong>\n<ul class=\"wp-block-list\">\n<li>Who specifically will monitor the metrics for success?<\/li>\n\n\n\n<li>How often will that individual monitor those metrics?<\/li>\n\n\n\n<li>For how long will those metrics be monitored?<\/li>\n\n\n\n<li>How will this ongoing monitoring be documented?<\/li>\n\n\n\n<li>What will you do to ensure that those metrics are met within the specified timeline?<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h2 id=\"plan-of-correction-support-from-quad-a\" class=\"wp-block-heading\">Plan of Correction Support from QUAD A<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The path to accreditation continues when you submit Evidence of Correction (EOC) showing that the identified deficiencies are now in full compliance with the corresponding standards. If you need support building your Plan of Correction,&nbsp;<strong>QUAD A<\/strong>&nbsp;is here to help.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Learn more about the accreditation process and take the first step toward accreditation today:\u00a0<a href=\"https:\/\/dev8.quada.org\/become-accredited\/\">https:\/\/dev8.quada.org\/become-accredited\/<\/a><\/p>","protected":false},"excerpt":{"rendered":"<p>The on-site survey is often seen as the final hurdle before accreditation. Healthcare leaders on the path to accreditation put considerable effort into making sure that their facilities are survey-ready and in compliance with&nbsp;QUAD A&nbsp;standards, but there\u2019s one more step that\u2019s just as important as the survey itself. The Plan of Correction (PoC) is the [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":1544,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[13,44,37],"tags":[],"class_list":["post-1545","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-accreditation","category-medicare-ambulatory-surgery-centers-accreditation","category-patient-safety"],"acf":[],"_links":{"self":[{"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/posts\/1545","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/comments?post=1545"}],"version-history":[{"count":3,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/posts\/1545\/revisions"}],"predecessor-version":[{"id":7128,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/posts\/1545\/revisions\/7128"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/media\/1544"}],"wp:attachment":[{"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/media?parent=1545"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/categories?post=1545"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/quada.org\/fr\/wp-json\/wp\/v2\/tags?post=1545"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}