If the AER identifies a situation that indicates the possibility of noncompliance, the AER will create an Action Item in discussion with operators staff to direct the operator to investigate the situation. The operator must investigate and, if necessary, prepare and implement a reasonable remediations plan.
For example, if the AER sees the compliance assessment score for a facility increasing from month to month to month, it suggests the operator is not reviewing and responding to the CAR. In this situation, the AER may create an Action Item to direct the operator to investigate.
Action Items are formal AER direction to operators to conduct investigations into indicators of potential noncompliance.
At most operators the goal is to avoid the additional scrutiny from the AER that comes with Action Items. Therefore, most operators decide to proactively investigate items on the CAR and implement remediation to reduce the risk of a reoccurrence.
To invite a Corvelle consultant to your office to describe how to avoid Action Items, please contact us.