photograph of a child
  • Use decisions on the level/extent and the root cause of the issue (Steps 2 and 3), including whether there is noncompliance, to determine:
    • At what level resolution needs to happen
    • Who needs to be responsible
    • What actions should be required
    • What data will be used to verify correction and how verification will occur
  • For improvement, develop improvement strategies and correlate with SPP/APR as appropriate
  • For correction of noncompliance, issue written finding notification (data/conclusion leading to finding of noncompliance, citation, requirement to correction as soon as possible but in no case later than one year from identification)