Corrective Action Plan (CAP) Guidelines

The Department of Human Services (Department) Bureau of Program Integrity (BPI) requests a Corrective Action Plan (CAP) from providers as part of the retrospective review process. A CAP is a step-by-step plan of action developed to achieve targeted outcomes for resolution of identified problems in an effort to:

  • Ensure that quality, accessible, and timely services are provided.
  • Comply with the Medicaid State and Federal regulations.
  • Improve processes/methods so that outcomes are more effective or efficient.
  • Achieve measurable improvement in the highest priority areas.
  • Eliminate repeated deficient practices.

Providers are responsible to correct identified areas of noncompliance. An effective CAP will identify program deficiencies, specify an efficient path toward overall improvement, monitor imposed changes (making adjustments as necessary), and improve accurate and expedient program delivery.

The CAP Process

  1. CAPs must be submitted 30 days following notification of the Department’s final findings.
  2. The Department reviews the CAP and:
        (a) Approves the plan and informs the provider that the corrective actions implemented are deemed sufficient to bring into full compliance with the requirement; or
        (b) Denies approval and informs the provider that some or all elements must be revised and resubmitted.
  3. Upon receipt of the Department’s acceptance of the CAP, the provider may be asked to submit evidence of compliance with the CAP. The Department may request progress reports relating to CAP compliance as appropriate.

Best Practices in CAP Development

An effective CAP will identify program deficiencies, specify an efficient path toward overall improvement, monitor imposed changes (making adjustments as necessary) and advance accurate and expedient program delivery. Items to consider when developing a CAP include:

  • How should this requirement be met?
  • Who will be responsible for the elements of the CAP?
  • What other processes or people are affected by implementing the CAP?
  • What policies/procedures, manuals, provider handbooks, contract templates, etc. need to be revised to reflect the change?
  • How will we know that we are achieving our goal?
  • How can we tell if our performance is what it should be?
  • What monitoring or management reports will let us know how we are doing and that the change was implemented correctly?

To develop an acceptable CAP, the provider should:

  1. Determine who has the knowledge and authority to make the decisions, to develop the plan, to require the changes, and to coordinate across functional areas of responsibility.
  2. Assign individual responsibility and an overall CAP coordinator role.
  3. Focus on error concentrations that have the most significant impact on the error rate.
  4. Identify the root cause of the error: when did it occur, and who or what caused it?
  5. Identify operational policies and procedures that caused the error.
  6. Develop a correction strategy that wholly addresses each deficiency.
  7. Identify major tasks required to implement the corrective action, sequential timelines addressing the most critical areas first, target implementation dates, and key personnel/components responsible for each action.
  8. Address practice/process, structure, training, communication needs, monitoring and follow-up activities.
  9. Assess proposed CAP for potential unintended consequences of system changes on other areas of the business; adjust as needed.
  10. Assess whether the corrective actions in place are effective at reducing or eliminating error causes.

When developing a CAP, providers should carefully review Medical Assistance (MA) regulations and interpretations of those regulations. View Medical Assistance RegulationsSearch for a Bulletin.

Please submit your CAP to the following address and include your 13-digit PROMISe provider number and service location:

Department of Human Services
Bureau of Program Integrity – DPPC/DPR
P.O. Box 2675
Harrisburg, Pennsylvania 17105-2675

If you have any questions relating to the development of a CAP, please call the Case Coordinator identified in your final findings letter.