Code & Name Prepared by Name & Title DATE: [mm/dd/yyyy] DATES OF PROG CLUSTER SCORES REPORT: Identification and Rationale Goals and Measures Monitoring Method(s) Responsible Evaluation Party Based on the Annual (12 month) State goal(s) for each specific Test Indicate how the program Indicate who is Identify how the Program Cluster Score Report, Content Cluster Area score below the to monitor its responsible to corrective actions will identify two or more scores or goal. performance to ensure that implement the be evaluated. mean (total) below goal IF the List and explain measure(s) to be implementation of the corrective first-time pass rate on the implemented or systemic changes to corrective action plan occurs action plan. Attach a sample of certification exam is below 90%. be made to ensure that the low and is maintained. program’s evaluation score(s) will not recur. Indicate who is form, if used. Attach a sample of responsible to Communicating Information Goal 50% program’s monitoring form, monitor for Performing Basic Nursing Skills if used. compliance. Goal 75% Performing Personal Care Skills Goal 75% Performing Basic Restorative Skills Goal 75% Providing Mental Health & Social Services Goal 50% Providing Resident’s Rights Goal 50%
Code & Name Prepared by Name & Title DATE: [mm/dd/yyyy] DATES OF PROG CLUSTER SCORES REPORT: Identification and Rationale Goals and Measures Monitoring Method(s) Responsible Party Evaluation Based on the Annual (12 month) Program Cluster Score Report, identify two or more scores or mean (total) below goal IF the first-time pass rate on the certification exam is below 90%. Communicating Information Goal 50% Performing Basic Nursing Skills Goal 75% Performing Personal Care Skills Goal 75% Performing Basic Restorative Skills Goal 75% Providing Mental Health & Social Services Goal 50% Providing Resident’s Rights Goal 50% State goal(s) for each specific Test Content Cluster Area score below the goal. List and explain measure(s) to be implemented or systemic changes to be made to ensure that the low score(s) will not recur. Indicate how the program to monitor its performance to ensure that implementation of the corrective action plan occurs and is maintained. Attach a sample of program’s monitoring form, if used. Indicate who is responsible to implement the corrective action plan. Indicate who is responsible to monitor for compliance. Identify how the corrective actions will be evaluated. Attach a sample of program’s evaluation form, if used.
CAP_Template_10_2018.docx