Summary
Department of Public Health (DPH) inspections evaluate healthcare and long-term care facilities across key operational categories such as Resident Rights, Nursing & Clinical Care, Administration & Staffing, Kitchen & Food Services, and Environment & Safety. When deficiencies or citations are identified during an audit, facilities must establish clear remediation steps. This article explains how frontline staff and department leads can leverage Survey Projects and Action Plans in Loop CXM to capture DPH inspection results, assign remediation tasks, track resolution timelines, and maintain regulatory compliance.
Prerequisites & Permissions
Before managing corrective actions in Loop CXM, ensure you have the following:
Primary Audience: Platform Administrators, Location Managers, and Benbria Internal Staff.
Permissions Required:
Account Owners: Full system access to create, edit, delete, group into folders, and share Dashboard Projects globally or assign them to specific locations.
Location Admins: Ability to view, filter, drill down into, and export dashboards assigned to their physical locations or business units.
Survey Project Setup: A configured DPH Inspection or Quality Audit survey project in the Loop Experience Platform.
Step-by-Step Instructions
Step 1: Access the DPH Survey Project
Log in to the Loop Experience Platform.
From the main navigation menu, click Projects and select the appropriate Survey Project (e.g., DPH Inspection Audit & Corrective Actions).
Click the Action Plans tab in the top sub-navigation bar.
Step 2: Create a New Action Plan for DPH Deficiencies
On the Action Plans page, click the + Create Action Plan button (or click the edit icon next to an existing plan title to rename it).
In the title field, enter a descriptive name for the corrective plan (e.g., DPH Survey Corrective Action Plan - Q3).
Under Plan Details, select the relevant Focus Area corresponding to the DPH inspection category (e.g., Nursing & Clinical Care, Kitchen & Food Services, Environment & Safety, or Resident Rights).
Define required Actions across three mandatory operational levels:
Immediate Action: Corrective steps taken right away to safeguard affected residents.
Systemic Action: Facility-wide policy updates, workflow redesigns, or mandatory staff retraining.
Monitoring Action: Scheduled rounding and audit checks performed by department leads to ensure ongoing compliance.
💡 TIP: Standardizing your Focus Areas to match official DPH operational categories ensures seamless tracking and audit readiness across departments.
Step 3: Add and Assign Specific Corrective Actions
Under your Action Plan, click + Add Action.
Enter a short, action-oriented title for the specific remediation task (e.g., Update Medication Administration Log and Retrain Staff).
Provide a clear description detailing the exact corrective steps required to resolve the cited deficiency.
In the Owner field, assign the task to the responsible frontline staff member or department lead.
In the Due Date picker, select the required deadline for completing the remediation.
Click Save or click outside the panel to finalize the action item.
Step 4: Track, Collaborate, and Update Action Status
As corrective tasks are carried out, open the action item from the Action Plans tab.
Use the Comments section at the bottom of the plan panel to post status updates, upload supporting evidence, or communicate with team leads.
Update the Status dropdown menu as work progresses:
Not Started – Action created but remediation has not begun.
In Progress – Remediation, retraining, or facility updates are actively underway.
Complete – Corrective action is fully resolved and verified.
⚠️ NOTE: Automated email notifications notify assigned owners when an action is created or when the status changes, ensuring accountability and momentum toward resolution.
Key Operational Categories for DPH Focus Areas
When setting up Focus Areas for DPH remediation, align them with the standard DPH survey categories:
Resident Rights: Privacy, dignity, autonomy, and grievance handling.
Nursing & Clinical Care: Medication administration, wound care, hygiene, and clinical documentation.
Administration & Staffing: Staffing levels, mandatory training, and administrative compliance.
Kitchen & Food Services: Food safety, sanitary preparation, and dietary requirements.
Environment & Safety: Infection control, physical plant maintenance, and building safety codes.
Here is the updated table including category descriptions, aligned with stable survey categories, focus areas, and structured Action Plans (Immediate, Systemic, and Monitoring Actions). Below the table is a section detailing how to promote and operationalize this DPH Action Plan example within your team and platform.
DPH Deficiency Mapping & Action Plan Examples
Focus Area | Category Description | Title | Deficiency Example (F-Tag / Specific Finding) | Action Plan & Actions |
Infection Prevention & Control
| Evaluates facility policies, surveillance, and daily clinical practices designed to prevent, investigate, and control communicable diseases and healthcare-associated infections. | Universal Precautions & Hygiene
| F880 - Infection Prevention & Control: Staff observed performing dressing changes for a pressure ulcer without changing gloves or performing hand hygiene between clean and dirty tasks.
| Immediate Action: Provide immediate 1-on-1 retraining for the nurse involved on proper aseptic technique.
Systemic Action: Conduct mandatory facility-wide in-service training on hand hygiene and glove changing protocols.
Monitoring Action: The Director of Nursing (DON) or designee will perform weekly random hand hygiene audits on 10 staff members across all shifts for 60 days.
|
Resident Rights & Safety
| Assesses adherence to protecting resident dignity, autonomy, personal property, and maintaining a safe, hazard-free physical environment.
| Accident Hazards & Supervision
| F689 - Free of Accident Hazards: Unattended chemical cleaning agents left in unlocked housekeeping carts inside accessible resident corridors, presenting an ingestion hazard.
| Immediate Action: Remove all unsecured hazardous chemicals from corridors and secure them in locked storage immediately.
Systemic Action: Revise housekeeping safety procedures and install self-locking compartments on all cleaning carts.
Monitoring Action: Environmental Services Supervisor will complete daily hallway rounding checklists for 30 days, transitioning to weekly audits thereafter.
|
Quality of Care
| Focuses on providing necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. | Resident Assessment & Notification
| F684 - Quality of Care / F580 - Notify of Changes: Failure by nursing staff to promptly evaluate a resident following a fall and delay in notifying the attending physician regarding a significant change in condition.
| Immediate Action: Assess the affected resident for potential injuries and immediately notify the attending physician and family.
Systemic Action: Update change-in-condition and post-fall assessment policies; re-educate all clinical staff on required documentation and notification timelines.
Monitoring Action: Unit Managers will review 100% of incident reports daily during morning clinical huddles for 90 days to ensure timely physician notification.
|
Food & Nutrition Services
| Examines how the facility stores, prepares, distributes, and serves food under sanitary conditions to prevent foodborne illness and satisfy dietary needs.
| Food Safety & Sanitation
| F812 - Food Safety & Store Sanitation: Unlabeled and undated leftover food items stored in the main kitchen walk-in refrigerator, exceeding safe storage timelines. | Immediate Action: Immediately discard all undated and expired food items stored in the walk-in cooler.
Systemic Action: Re-train kitchen staff on food storage, labeling, and dating protocols according to food safety standards.
Monitoring Action: The Dietary Manager will conduct daily walk-in cooler inspection logs for 4 weeks, followed by twice-weekly audits for 2 months.
|
Pharmacy Services | Monitors the management, acquisition, administration, and disposal of all drugs and biologicals to minimize medication errors and adverse drug reactions.
| Medication Administration
| F759 / F760 - Medication Errors: Failure to follow physician orders regarding time-sensitive insulin administration, resulting in a medication error rate exceeding 5%. | Immediate Action: Complete a clinical reassessment of affected residents and report the error to the attending physician and pharmacist.
Systemic Action: Conduct mandatory medication pass competency evaluations for all licensed nurses.
Monitoring Action: The Consultant Pharmacist and DON will conduct monthly random medication pass audits on 5 nurses across varying shifts.
|
How to Promote the DPH Action Plan Example
To promote this DPH Action Plan structure across long-term care operations, sales enablements, and quality compliance teams, emphasize how structuring corrective actions mitigates regulatory risk and speeds up survey remediation.
Standardize Plan of Correction (PoC) Workflows: Highlight this 3-tier structure—Immediate, Systemic, and Monitoring actions—as the benchmark format required by Department of Public Health (DPH) surveyors to demonstrate complete survey readiness.
Integrate with Benbria Loop Experience Platform: Demonstrate how these exact survey categories, focus areas, and action steps map directly into Loop Experience Platform Action Plans, enabling department leads to assign owners, track due dates, and attach audit evidence digitally.
Leverage in Sales & Marketing Pitching: Position this example in product demonstrations to show Skilled Nursing Facility (SNF) Administrators and Directors of Nursing how digital action planning turns state citations into auditable, closed-loop remediation workflows.
Train Quality Improvement (QAPI) Committees: Use this table in staff training modules to ensure leadership teams understand how routine monitoring actions feed directly into quarterly QAPI review dashboards and continuous quality monitoring.
Troubleshooting & FAQs
Q: Who can see or edit the Action Plans created for DPH inspections?
A: Action Plans inherit the visibility permissions of the parent Survey Project. Staff members assigned as Owners receive direct notifications, while admins and location managers can view and manage all plans within their assigned locations.
Q: Can I assign multiple team members to a single action item?
A: Each action item has one primary Owner to ensure distinct accountability. For complex corrective tasks involving multiple staff members, create individual action steps under the same Action Plan and assign each to its respective team lead.
Q: What happens if a DPH corrective action due date is missed?
A: Action items with past-due target dates remain marked as In Progress or Not Started and are flagged in dashboard views, allowing management to follow up immediately.
Request a Demo
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Request a Demo today to connect with a Benbria Product Specialist for a personalized walkthrough tailored to your operational goals.