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Corrective Action Plan Guide for Agencies

The document provides guidelines for submitting a Corrective Action Plan (CAP) to the Department of Mental Health (DMH) following a review of an agency's compliance with Minimum Standards. DMH's review of <Select DA> found areas that did not meet standards, requiring the agency to develop a CAP within 30 days. The CAP must describe actions and timeframes to address each unmet standard and be completed within 6 months of DMH approval. DMH will follow up to ensure all items in the plan are addressed on time.

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165 views2 pages

Corrective Action Plan Guide for Agencies

The document provides guidelines for submitting a Corrective Action Plan (CAP) to the Department of Mental Health (DMH) following a review of an agency's compliance with Minimum Standards. DMH's review of <Select DA> found areas that did not meet standards, requiring the agency to develop a CAP within 30 days. The CAP must describe actions and timeframes to address each unmet standard and be completed within 6 months of DMH approval. DMH will follow up to ensure all items in the plan are addressed on time.

Uploaded by

sarge18
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

GUIDELINES FOR SUBMITTING A CORRECTIVE ACTION PLAN

The Adult Mental Health (AMH) Minimum Standards and Clinical Care Review is conducted every four
years at each Designated Agency/ Specialized Services Agency by staff of the Adult Mental Health
Division of the Department of Mental Health. The review offers opportunities to recognize the agency’s
accomplishments, observe practice patterns, and ensure compliance with Minimum Standards. The
findings are a required part of agency redesignation and can also be used by the agency to contribute to
their quality management plans. DMH’s Clinical Care and Minimum Standards Review of <Select DA>
CRT client records and Emergency Services records conducted on <Date> found that documentation
overall was consistent with the provision of quality services; however, there were multiple areas that did
not meet Minimum Standards requirements that will necessitate the development and implementation
of a Corrective Action Plan.

Guidelines for Submitting Corrective Action Plan

Please email a Corrective Action Plan to the email address below. For your convenience, DMH has
created a template. You may use this template or develop your own Corrective Action Plan form. If you
create your own version, it must include all informational components of the DMH template. Technical
assistance is available from DMH throughout this process.

<AMH Quality Coordinator Name>


Quality Management Coordinator
Department of Mental Health
Agency of Human Services
<Email Address>
<Phone Number>

Within 30 days of receipt of the final AMH Clinical Care and Minimum Standards Review Report, <Select
DA> must submit a Corrective Action Plan to DMH by <Date> for review and approval. The CAP must
include a description of each action to be taken and timeframe of how <Select DA> plans to address
each requirement listed to meet the related unmet Minimum Standard. The completion of the CAP
must occur within six months or less from the time of DMH’s approval of the plan.

DMH will follow up with <Select DA> to ensure that all the items included in the plan have been
effectively addressed within the plan’s timeline.
DMH Corrective Action Plan
<Select DA>

Return to DMH by <Date> Chart Review Timeframe: <Enter Date Range>


Completed by: <Name of DA point person> Chart Review Date: <Date>
Job Title: <Title of DA point person
Date Completed: <Date>

Section Number for Requirement Completion Date


Action to be taken
by <Date>
(Actual or
Estimated)
Example:
Section 7. Individual Plan of Care
All IPCs must include:

 the signature of the individual


served, their legal guardian, or
document clearly why the
client/guardian signature is
absent (e.g. refusal).

 Frequency range of services for


each service prescribed in the
IPC.

Client-driven goal development, as


evidenced by documentation of direct
quotes or summaries for each of a
client’s individual goals that are then
clinically interpreted into mental health
treatment goals.

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