Alternative Compliance Option for CoC Standard 4.2

If a program due for a site visit in 2024 determines it is not currently capable of meeting the measures of compliance required by CoC Standard 4.2: Oncology Nursing Credentials, then the program is allowed to develop and implement a corrective action plan to help achieve compliance.

The corrective action plan must outline the specific issue(s) affecting compliance and the interventions that will be implemented to achieve compliance. The specifics of the action plan must be documented in the cancer committee minutes. Successful documentation of a substantive action plan will result in a “deficient but resolved” rating during the 2024 site visit. This acknowledges that the program did not meet the measure of compliance for Standard 4.2 but does not impact the program’s accreditation status or require submission of corrective action materials to resolve the standard.

At the end of the corrective action plan, the cancer program is expected to be fully compliant with Standard 4.2: Oncology Nursing Credentials. This will be reviewed at the program’s next site visit in 2027.

At this time, the corrective action plan is a temporary alternative compliance pathway for 2023 and 2024 site visits only.

Questions related to this alternative pathway to Standard 4.2 compliance may be submitted to the CAnswer Forum.