The Corrective Action Plan or CAP is a process that consists of a form and instructions that allows one to systematically respond to each major deficiency as required per the Program Rules. All required CAPs are due within 45 days of your audit summary, submitting only one (1) CAP per form. All major deficiencies are required and are designated by a rating of “1”. Additionally, all minor deficiencies are required on initial certification audits or when the minor deficiencies amount to a total of 5 or more deficiencies. Minor deficiencies are designated by a rating of “2”.

The CAP process:

1. When one is ready to submit the CAP, the first step is to provide the date and required company contact information, followed by the audit deficiency number and a detailed description of the deficiency.

2. The second step in the process is to document the Root Cause Analysis, which is a detailed explanation of why the deficiency happened or what caused it to occur. Common concerns are lack of training, negligence, or procedural issues. Include the name and title of the person responsible for the oversight.

3. The next step is defined as the Corrective Action, which specifically is asking for a detailed explanation as to how the deficiency is being rectified. You will want to list specific steps in the process.

4. The fourth step is simply identifying who is responsible for implementing and oversight of the Corrective Action.

5. The final step in the process outlines what is specifically being done to ensure this deficiency doesn’t reoccur or happen in the future, supported by a detailed explanation and implementation date.


For any further questions/concerns about how to implement a Corrective Action Plan, contact Henry Arato.