Plan of Improvement Template

Provider Name:  _____________________________________________________
 Region: ____________

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

Item Numbers Descriptors
1 No valid note documenting the service could be located.
2 Note describes a service intervention or activity that is not billable.
3  Service provided by unqualified staff.
4 No amount of time documented.
No valid Mental Health Assessment could be located.
6 No valid Individual Treatment Plan could be located.
7 Specific service does not appear on ITP.
8 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.
10  Location of service not correctly noted on-site vs. off-site
11 Note describes a different service than billing submitted.