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Run: F-Tag Deficiency Corrective Action Plan

Use this F-Tag Deficiency Corrective Action Plan template to document the cited F-tag, immediate resident-safety fixes, root cause, systemic corrections, and...

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Citation Overview

Facility Name (required)

Survey Date (required)

F-Tag Number (required)

Citation Summary (required)

Briefly describe the cited deficiency and the affected process or resident care area.

Immediate Corrective Actions

Immediate Actions Taken (required)

Describe what was done right away to address the deficiency and protect residents.

Resident Safety Impact (required)

Containment Completed Date

Date immediate containment actions were completed.

Root Cause Analysis

Root Cause (required)

State the primary cause of the deficiency.

Contributing Factors (required)

Analysis Method Used

Systemic Corrective Actions

Corrective Actions (required)

Add each corrective action as a separate item.

Policy or Procedure Updates Needed

Yes No N/A

Staff Retraining Required

Yes No N/A

Training Scope

Monitoring and Verification

Monitoring Plan (required)

Describe the audit or observation process, frequency, and responsible role.

Monitoring Frequency (required)

Target Completion Date (required)

Verification Owner (required)

Role responsible for verifying sustained compliance.

Leadership Attestation

Prepared By (required)

Title / Role (required)

Attestation (required)

Yes No N/A

Signature (required)

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Email (required)

Your name (optional)

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