Summary / Overview
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:
User Permissions: Frontline Staff, Location Manager, or Account Admin access with permissions to view and update Survey Projects and Action Plans.
Survey Project Setup: A configured DPH Inspection or Quality Audit survey project in Loop CXM.
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).
đĄ TIP: Standardizing your Focus Areas to match official DPH operational categories ensures seamless tracking and audit readiness across departments.
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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.
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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 â Action created but remediation has not begun.
In Progress â Remediation, retraining, or facility updates are actively underway.
Complete â Corrective action is fully resolved and verified.
â ď¸ NOTE: Automated email notifications notify assigned owners when an action is created or when the status changes, ensuring accountability and momentum toward resolution.
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Technical & Operational Details
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.
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.
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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.