Monitoring a Corrective Action Plan (CAP)

9035.3.2 – Monitoring a Corrective Action Plan (CAP) (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The QIO Sanction Panel should monitor and review the outcome of a CAP and determine if the actions a practitioner takes are acceptable. The practitioner or other person must demonstrate improvement using quantifiable measures; CMS recommends that CAPs be monitored over a twelve (12) month period. The QIO Sanction Panel should, at minimum, evaluate the practitioner’s results on a quarterly basis. • If at any time the QIO Sanction Panel identifies additional gross and flagrant violations or a substantial violation in three or more instances, the Sanction Panel should initiate the sanction review process by making a referral for an initial finding as described in Sections 9020.1 and 9025 above. • The QIO Sanction Panel may end the CAP before its planned end to pursue a sanction recommendation to OIG if the Sanction Panel determines patients to be in imminent danger. • After the CAP ends, if the QIO Sanction Panel determines that the CAP resulted in measureable improvement and that the finding has been resolved to the QIO’s satisfaction, the case should be closed as resolved. • If after the CAP ends, the QIO Sanction Panel determines the results not to be acceptable, the QIO refers the matter to OIG. (See §9040.1.) The QIO Sanction Panel’s finding shall be based on majority vote.