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Additional Information from Provider Certification

Instructions for Corrective Actions

Frequently, Provider Certification will be required to request corrections from organizations following the provider’s on-site or desk review.

Corrections will be requested via an email that is sent to the provider’s contact of record. This email will include one or two reports, Actions Needed (ANC) for Necessary Standards and/or a Plan of Correction (POC) for Critical Standards.

Responses must be completed on the form(s) and submitted to Provider Certification. Only the ANC and/or POC should be submitted back to Provider Certification. Any additional documentation submitted will not be reviewed.

Provider Certification will review the ANC and/or POC and will then correspond with the provider regarding what is needed.


Here are things to keep in mind when filling out these documents:

Finding: What was found to not be in compliance?” This section will be completed by Provider Certification and will cite the standard and element(s) found to not be in compliance. It will also state why it was found to not be in compliance.

Corrective Action: “What will the provider do to correct the deficiency?” This is specific to each finding. Here the provider will describe what they will do to bring the program into compliance, by fixing the non-compliant finding.

Date Complete: “When will it be corrected?” This is the actual date the corrective actions will be put in place.

Person Responsible: “Who is responsible for ensuring that the finding is corrected?” The name and title of the person is listed that will be accountable for ensuring that the finding is corrected.

On-Going Monitor Process: “How will the provider prevent this from re-occurring?” The provider will describe the mechanism established that will be put in place to prevent the finding from re-occurring. In addition to the mechanism, the time frame for how often it will take place is also required.

Required Signatures: Signatures of a Board member, their title, and the Program or Executive

Director, and their title are required to be dated and in place on the form when returned to

Provider Certification. The ANC and POC will not be accepted without the required signatures.

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