Corrective Action Plan and Documentation of Corrective Action

1. Corrective Action Plan and Documentation of Corrective Action

2. Agenda • What is a corrective action plan? • Why are they required? • Important parts of a corrective action plan • Proper documentation needed to meet a corrective action • Examples of documentation requests for corrective action plans • Example of a proper corrective action document submittal • Closing a corrective action.

3. What is Corrective Action? • If the institution is found out of compliance, State Agencies are required to apply a corrective action to the institution whereby the institution must supply a plan of correction within a specific time frame. • The plan may be written or the reviewer may choose to go back out to the institution to see the corrected activity. • If written (most common method), the response submitted must address each finding and include the actions being implemented by the institution to permanently correct the deficiencies found.

4. Why Are They Required? • Technical assistance on the non – compliance matter is often given during an AR. Requiring an institution to develop a corrective action response further helps the institution to: • Understand what the institution and/or staff is doing incorrectly and what they need to do to make improvements • Document the institution’s plan for improvement • Allow the SA to evaluate the institution’s understanding through the corrective action plan and documentation. Additional information may be needed. • Sufficient detail is needed so that any follow-up reviews by the State Agency or USDA through an ME can determine whether the issues were corrected and if those corrections have been permanently maintained.

5. Important Parts of a Corrective Action Plan • The corrective action plan must clearly answer the following: • What • Why • How • When • Who

6. What • The institution must clearly establish what the problem is • Example: • Income eligibility forms for two children were incorrectly approved for free. Both these forms were missing case numbers resulting in an incomplete form.

7. Why • The institution must identify why the problem is occurring • Example: • The new assistant director was not adequately trained on approving income eligibility forms prior to being hired. There is no edit check process in place to ensure the forms are completed and accurately approved prior to claim submission by the new person.

8. How • The institution must identify how the problem can be prevented or eliminated. • This cannot be an assurance that the mistake will not happen again. • The solution must be a process – specific steps that have been taken to correct the deficiency and what extra steps will be taken to make sure this problem does not occur again.

9. How • Example: • All new hires for the assistant director position will receive training from the director on approving income eligibility forms prior to this responsibility. The assistant director will approve all of the income eligibility forms that are returned by participants and the director will review all of the approved income eligibility forms to ensure they are completed and accurately approved by the assistant director. If the director does not agree with the assistant director on the approval of the form, they will discuss this discrepancy together to come to an agreement on the correct approval.

10. When • The institution must state when the issue was corrected. • This may also include how often the new procedure will be done; ie. daily, weekly, monthly • The time frame will usually be less than 30 days if not immediately. • Example: • On April 13, 2018 the assistant director was re-trained on how to accurately approve income eligibility forms and what must be on the form in order for it to be considered a completed form. • Once the assistant director approves a new income eligibility form, the director will review the form to ensure it is accurately approved by the end of each month prior to claim submission.

11. Who • The institution must list who will be responsible for ensuring the corrections were made and written policies and/or procedures will be maintained. • Example: • As part of the new hiring orientation, the new assistant director will be trained by the director on approving income eligibility forms. The assistant director will be responsible for approving all income eligibility forms returned by participants. The director will double check all income eligibility forms after they have been approved to ensure they are correct prior to claim submission.

12. Supporting Documentation • The institution will submit further documentation to establish that the finding has been permanently corrected. • Example: • Please see the attached training agenda and attendee signature from the April 13, 2018 training. • Please see the new hire assistant director orientation packet which includes a section of training on approving income eligibility forms.

13. Supporting Documentation • Additional Examples: • Missing information on income eligibility forms: submitted completed income eligibility forms • Non-compliant meals served: copy of the upcoming menu showing all of the meals planned to be served • No staff training: copies of training documentation such as agendas, PowerPoint slides, and sign-in sheets • Late claims (after the 60 day deadline): a new policy on claim submission each month

14. Acceptable Corrective Action • When the corrective action plan is received from an institution, the State Agency evaluates the submission it to ensure that it is complete and that the finding(s) has been adequately addressed. • If the State Agency determines the institution’s response is satisfactory, the State Agency will issue a letter to the institution indicating that its response was acceptable and the review will be closed.

15. Comprehensive Corrective Action Plan: Example • Finding: • During an administrative review, it was discovered that the institution has recordkeeping violations. The institution did not have production records for the week of review for the meals that were prepared and served to the children/students each day.

16. Appropriate Corrective Action Plan: Example • The written corrective action plan submitted: • The institution did not have production records for the meals prepared and served during the week of review because the cook was out sick and the assistant cook was not aware they had to complete them. On May 1, 2018 the institution’s assistant cook was trained on how to accurately complete the production record at the time of meal service. The center has created a policy that if the cook is out sick, the assistant cook will complete these records. At the end of each day, the cook or assistant cook will be required to give the completed production records to the foodservice coordinator. The foodservice coordinator will review these records for completeness each day. Please see the attached training agenda and attendee’s signature for the training and the month of May’s production records.

17. Inappropriate Corrective Action Plan Example • Finding: • During an administrative review, it was discovered that the institution has recordkeeping violations. The institution was not maintaining production records for the meals that were prepared and served to the children/students each day. • The written corrective action plan submitted: • The institution will re-train kitchen staff and in the future they will comply with all federal recordkeeping requirements. • This does not provide enough information to ensure the institution has permanently corrected the above issues.

18. If Inappropriate Corrective Action Received • If the corrective action response is incomplete, the State Agency will inform the institution of all outstanding items and allow additional time for the institution to submit the remaining documentation. • If the corrective action response is not submitted and/or the additional documentation is inadequate and they refuse to make the required correction, the State Agency must proceed to withhold claims from the institution until the correction is made appropriately.

19. Questions?