US · guidance
CMS Pub. 100-10, ch. 9, § 9035.3.2
Monitoring a Corrective Action Plan (CAP)
The QIO Sanction Panel should monitor and review the outcome of a CAP and determine
if the actions a practitioner takes are acceptable. The practitioner or other person must
demonstrate improvement using quantifiable measures; CMS recommends that CAPs be
monitored over a twelve (12) month period.
The QIO Sanction Panel should, at minimum, evaluate the practitioner’s results on a
quarterly basis.
• If at any time the QIO Sanction Panel identifies additional gross and flagrant
violations or a substantial violation in three or more instances, the Sanction Panel
should initiate the sanction review process by making a referral for an initial
finding as described in Sections 9020.1 and 9025 above.
• The QIO Sanction Panel may end the CAP before its planned end to pursue a
sanction recommendation to OIG if the Sanction Panel determines patients to be in
imminent danger.
• After the CAP ends, if the QIO Sanction Panel determines that the CAP resulted in
measureable improvement and that the finding has been resolved to the QIO’s
satisfaction, the case should be closed as resolved.
• If after the CAP ends, the QIO Sanction Panel determines the results not to be
acceptable, the QIO refers the matter to OIG. (See §9040.1.) The QIO Sanction
Panel’s finding shall be based on majority vote.
History
(Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
15dc13ccdbd16e1f62cae208d21ced2c151fc540f24bd1e243c19bfd3ee55f77
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