Plan of Improvement Template
Provider Name: _____________________________________________________
Provider Staff Completing Form _________________________________________
Date of POI___________
Type of Review: PPR Review Date: ______________
Note: A separate POI form must be completed for each item below threshold and/or if the overall substantiated score was below 70%.
Issue to Address (Number and description of tool item which was below threshold or overall score below 70%):
Improvement Activities (How the finding will be corrected [step-by-step plans], including how the overall systemic problem(s) which led to the finding will be addressed [i.e., staff training, supervisory review, quality assurance review of documentation. etc.], the person responsible for completing the activity, and the date that the improvement activity will be first implemented):
Expected Outcome (What is expected to occur as a result of implementation of the improvement activities. Include date specific expected outcome is met):
Signature with Title Date
FY14 Guide to Post-Payment Review (PPR) Item Numbers with Descriptors
||No valid note documenting the service could be located.
||Note describes a service intervention or activity that is not billable.
|| Service provided by unqualified staff.
||No amount of time documented.
||No valid Mental Health Assessment could be located.
||No valid Individual Treatment Plan could be located.
||Specific service does not appear on ITP.
||ITP review does not demonstrate both a review of progress towards goals and an evaluation of needed services.
||Time billed is greater than time documented.
||Location of service not correctly noted on-site vs. off-site
||Note describes a different service than billing submitted.