Writing a
Comprehensive
Corrective Action Plan
Patty Carignan
Program Specialist
Agenda
• Discuss what a corrective action plan is
• Why are facility required to submit corrective action plans?
• What must be included in a corrective action plan?
• Examples of comprehensive corrective action plans
• Examples of unacceptable corrective action plans
• Activity: Writing a comprehensive corrective action plan
• Activity: Determining if the corrective action submitted is acceptable.
What is Corrective Action?
• The action the facility will take within a specific timeframe to
address the finding(s) or non-compliance and to prevent it
from recurring. 2 CFR 200.26
• Facilities are required to provide a written corrective action
response to the review findings within the timeframe
designated by the State Agency.
Corrective Action
Corrective
Action
• New or improved processes or
procedures
• Implemented within a specific
time frame
• Expected to resolve the
condition that resulted in
noncompliance
• Expected to prevent recurrence
• Identifies who is responsible for
implementing and maintaining
new processes or procedures
Why Are You Required to Submit
Corrective Action?
• Requiring a facility to develop a corrective action response assists in:
• Understanding what the facility and/or staff is doing incorrectly and what
they need to do to make improvements
• Document the facility’s plan for improvement
• Provide an opportunity for the State Agency (SA) to evaluate and accept the
corrective action or request additional information or clarification
• Provide sufficient detail so that during any follow-up reviews it can be
determined whether the issues were corrected and those corrections have
been permanently maintained.
Why
• The institution must identify why the problem is occurring
• The 5 Whys that you need to ask are:
What Who How When Where
Root-Cause Analysis
Examples of Why Questions to Ask
Let’s say that the SA is on-site conducting a meal-service
observation and notice the cook is serving orange drink for the
fruit/vegetable component for breakfast. Upon questioning the
cook, she indicates that the orange juice is listed on the posted
menu for the day. However, no orange juice is available. All
they have is milk, full-strength apple juice, and orange drink. In
order to stay as close as possible to the posted menu, she
decided to serve the orange drink since it has vitamin C and
pictures of fresh-cut oranges on the container. The cook said
she did not know that orange drink did not meet meal-pattern
requirements. As such, the SA cites the facility for failure to
meet the meal-pattern requirements noted in 7 CFR 226.20(c)
5 WHYs Method
▪ Why was the meal not reimbursable?
▪ Because – the meal failed to meet meal-pattern requirements
▪ Why did the cook not serve orange juice for breakfast?
▪ Because – other than milk and full-strength apple juice, the
orange drink was the only drink available to serve.
▪ Why did the cook select the orange drink?
▪ Because the cook wanted to serve something close to the posted
menu as possible.
▪ Why did the cook assume the choice was acceptable?
▪ Because it appeared to be similar to orange juice. It had pictures
of fresh-cut oranges on the label, and it included the wording
“naturally flavored” and it had Vitamin C.
Root-Cause
• Now that we have asked all the Why’s what
do we think would be the Root-Cause?
Lack of Training
Corrective
Action
Plan
• Details step by step actions.
• Actions must resolve the
root-cause condition that
resulted in the
noncompliance.
• Actions must prevent
recurrence.
• Process and procedures are
consistent with federal
regulations, State Policy, and
organization requirements.
Developing the Corrective Action
Plan
What
• What processes and procedures will be implemented to correct the
finding?
Who
• Who is ultimately responsible for implementing the processes and
internal controls?
How
• How will the facility ensure the processes and procedures are followed
consistently to prevent recurrence?
When
• When will the processes and procedures be implemented and at what
frequency?
Where
• Where will the documentation be retained?
CAP Supporting
Documentation
• Income eligibility forms
• Enrollment forms
• Menus
• Child nutrition (CN) labels /
manufacturers’ product
formulation statement
• Recipes
• Attendance records
• Meal-count forms
Activity CAP Analysis
Activity CAP
Analysis
1.In your team, read and
discuss the finding and
required action.
2.Determine the root-
cause using the 5 Whys
method.
3.Evaluate the CAP using
the CAP checklist.
Acceptable? Why? Why
Not?
4.Be prepared to report
your decisions.
Developing the Corrective Action
Plan
What
• What processes and procedures will be implemented to correct the
finding?
Who
• Who is ultimately responsible for implementing the processes and
internal controls?
How
• How will the facility ensure the processes and procedures are followed
consistently to prevent recurrence?
When
• When will the processes and procedures be implemented and at what
frequency?
Where
• Where will the documentation be retained?
Debrief
Monitoring a CAP
____________________________
• Accept the CAP
• Verify Implementation
• Conduct follow-up visits
(if needed)
Best Practices for Sustainability
• Provide on-going training on all
policy and procedures
• Develop a facility specific training
program to address
noncompliance
• Monitor your facility on a quarterly
basis
• Establish and document policies
for responding to a corrective
action and for writing CAP’s
• Conduct follow-up visits to review
the CAP
• What additional best practices
would you recommend??
Activity: Developing a CAP
• Work with a partner to write your CAP
• Review the finding and determine the root-cause using
the five whys method.
• Develop a CAP using what, who, how, when and where
ACTIVITY: DEVELOPING A CAP
Root-Cause Analysis: 5 Whys Method
1. Why? Why were meals disallowed? Because the meals did not
meet meal pattern requirements.
2. Why? Why did the meals not meet meal-pattern requirements?
Because the meals did not have credible food.
3. Why? Why was the food not credible? Because the cook failed to
follow meal pattern requirements?
4. Why? Why did the cook fail to follow meal-pattern requirements?
Because the cook was not trained on the current meal-pattern.
What is the Root-Cause – Lack of training on the current meal-pattern
and edit checks for reimbursement.
What should your CAP look like
• Put CAP on your Letterhead
• Write down your responses for your CAP
• Sign and Date your CAP
• Add any attachments
• Send to the State Agency for Review
REVIEW - RECAP
• Purpose of corrective
action
• Root-cause analysis
• Corrective Action plan
requirements
• Components of a CAP
and evaluating
effectiveness
• Best Practices
Questions?
THANK YOU!
