Compliance Services Authority

Compliance Corrective Action Plans: Development and Execution

A compliance corrective action plan (CAP) is a structured, documented response to an identified deficiency, violation, or control failure within an organization's compliance program. CAPs operate across federal and state regulatory frameworks — from the Department of Health and Human Services Office for Civil Rights to the Occupational Safety and Health Administration — and represent the operational bridge between finding a problem and demonstrating remediation. This page covers how CAPs are defined, how they are structured and executed, the regulatory contexts that most commonly trigger them, and the criteria that determine when one approach is appropriate over another.

Definition and scope

A corrective action plan is a formal document that identifies a specific compliance deficiency, assigns accountability for resolution, establishes measurable remediation steps, and sets a deadline for completion and verification. The scope of a CAP can range from a single failed internal control — such as an expired employee training record — to a systemic breakdown requiring organizational restructuring.

Regulatory bodies define CAP requirements with varying degrees of specificity. The Centers for Medicare & Medicaid Services (CMS) requires CAPs as a condition of continued participation when a provider fails a certification survey (CMS State Operations Manual, Chapter 7). The Office for Civil Rights (OCR) under HHS routinely requires covered entities to submit and complete CAPs as part of HIPAA resolution agreements. OSHA uses the equivalent structure — formally called an "abatement plan" — when issuing citations under 29 CFR 1903.19 (OSHA Standards, 29 CFR 1903.19).

CAPs are distinct from corrective action notices (CANs), which are one-directional communications from a regulator. A CAP is a two-way instrument: the regulated entity proposes the remediation pathway and the regulator either accepts, rejects, or modifies it. This bidirectional accountability is what gives CAPs their legal and operational significance within broader compliance enforcement actions.

How it works

The development and execution of a CAP follows a reproducible sequence of phases regardless of the regulatory framework involved.

  1. Root cause identification — Before drafting remediation steps, the underlying cause of the deficiency must be isolated. Surface-level fixes without root cause analysis produce recurrence. Tools such as fishbone diagrams and the Five Whys method are commonly used at this stage.
  2. Deficiency documentation — The specific finding, the standard or regulation violated, and the date of discovery are recorded. This record anchors all subsequent CAP elements.
  3. Remediation action assignment — Each corrective action is tied to a named responsible party with an explicit role title, not just a department. Diffuse ownership is a primary failure mode in CAP execution.
  4. Timeline establishment — Completion dates are set for each action item. Regulators including CMS and OCR typically specify maximum timeframes — 45, 60, or 90 days are common windows — within which initial corrective steps must be demonstrated.
  5. Resource allocation — Budget, staffing, or technology changes required to execute remediation are identified and authorized before the CAP is submitted.
  6. Implementation and monitoring — Actions are executed per the assigned timeline. Progress is tracked against milestones. Internal audit functions verify interim completion.
  7. Verification and closure — The responsible compliance officer or external auditor confirms that the deficiency has been resolved and that the corrective control is operating effectively. Documentation of this confirmation is retained.
  8. Preventive controls integration — The final phase embeds lessons from the CAP into policy updates, training programs, or monitoring protocols to prevent recurrence. This connects CAP execution directly to compliance monitoring and auditing cycles.

Common scenarios

Corrective action plans arise in at least four distinct regulatory contexts, each with different procedural expectations.

Healthcare and HIPAA. OCR has issued resolution agreements requiring CAPs in cases involving inadequate access controls, failure to conduct required risk analyses, and impermissible disclosures of protected health information. These CAPs typically span 2 to 3 years and require annual reporting to OCR (HHS Office for Civil Rights, Resolution Agreements).

Workplace safety. When OSHA issues a serious citation, the employer must submit an abatement plan that functions as a CAP, including photographic or documentary evidence of completed corrections. Failure to abate carries per-day civil penalties (OSHA Penalties, 29 CFR 1903).

Financial services and banking. Federal Reserve, OCC, and FDIC enforcement actions — including Matters Requiring Attention (MRAs) and Matters Requiring Immediate Attention (MRIAs) — require written CAPs as the primary response mechanism. MRIAs carry shorter remediation windows than MRAs and may require board-level sign-off.

Environmental compliance. EPA consent orders and compliance schedules issued under the Clean Water Act or Resource Conservation and Recovery Act (RCRA) function as regulatory CAPs. These frequently include interim milestones and third-party auditor involvement (EPA Enforcement Actions).

Decision boundaries

Not every finding requires a full CAP. Organizations apply several criteria to determine the appropriate response level.

A minor administrative CAP applies when the deficiency is isolated, non-recurring, and does not involve a reportable violation. Documentation of the finding, a single corrective action, and a short completion window — typically 30 days or fewer — are sufficient.

A structured CAP applies when the deficiency reflects a process breakdown affecting multiple transactions, individuals, or records. This tier requires root cause analysis, multi-step remediation, and formal sign-off by a compliance officer as described in compliance officer roles and responsibilities.

A regulatory CAP is externally mandated — filed with or approved by the relevant agency — and includes submission deadlines, reporting intervals, and consequences for non-completion. This category is non-discretionary once a formal enforcement action has been issued.

The boundary between a structured internal CAP and a regulatory CAP is determined by whether a government agency has taken formal action. If a Notice of Violation, citation, or consent order has been issued, the CAP process falls under the agency's procedural requirements, not solely the organization's internal policies.

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