2nd Component - The Deficient Practice Statement

The Deficient Practice Statement indicates the part of the requirement that is not met. It summarizes the issues that demonstrate the facility's actions or failures to act that resulted in noncompliance with the requirements.

It also includes the extent of the deficient practice.  This is the number of individuals (or items) affected or potentially affected by the deficient practice (e.g., 4 out of 6 individuals were affected by the deficient practice, or 3 out of 7 individuals with behavior intervention plans, or 15 out of 47 sprinkler heads).

 

Example:

Based on observations, interviews, and record reviews, the facility failed to develop training programs for individuals who demonstrated that they needed assistance in dressing themselves for 4 of 6 individuals (Individuals #s 1, 2, 3, and 4).