INDEPENDENT HEALTH FACILITIES POST-ASSESSMENT ACTION PLAN – Facility Name & IHF #: Date Completed: RECOMMENDATION FROM ASSESSMENT POST ASSESSMENT ACTION PLAN - ACTION BY DATE EVIDENCE REPORT CORRECTIVE ACTION RECOMMENDATION PROVIDED TO (WHO IS RESPONSIBLE or WHO IS MONITORING) MET CPSO (LIST IN ORDER AS THEY APPER IN FINAL (WHAT ACTION IS BEING TAKEN) RECOMMENDATION SECTION) (WHEN) (PLEASE ATTACH AND IDENTIFY BY RECOMMENDATION #) This post assessment action plan was approved and signed off by: Name: Name: ______________________________ _______________________________________ Signature Licensee Signature Quality Advisor
INDEPENDENT HEALTH FACILITIES – POST-ASSESSMENT ACTION PLAN Facility Name & IHF #: Date Completed: RECOMMENDATION FROM ASSESSMENT REPORT (LIST IN ORDER AS THEY APPER IN FINAL RECOMMENDATION SECTION) POST ASSESSMENT ACTION PLAN - CORRECTIVE ACTION (WHAT ACTION IS BEING TAKEN) ACTION BY (WHO IS RESPONSIBLE or WHO IS MONITORING) DATE RECOMMENDATION MET (WHEN) EVIDENCE PROVIDED TO CPSO (PLEASE ATTACH AND IDENTIFY BY RECOMMENDATION #) This post assessment action plan was approved and signed off by: Name: Name: ______________________________ _______________________________________ Signature Licensee Signature Quality Advisor
IHF-action-plan-template.docx