Certainly, creating an entire action plan requires a significant amount of detail, but I can provide you with an outline that you can expand upon for each section of the plan. The action plan should cover various aspects, including leadership, culture, communication, policies, and procedures. Below is a structured outline to guide your Action Plan: Title: Preparing for Joint Commission Accreditation I. Introduction Brief overview of the long-term care facility. Rationale for pursuing Joint Commission accreditation. Importance of the accreditation for residents, staff, and stakeholders. II. Leadership and Governance A. Leadership Commitment and Responsibilities 1. Identify executive leadership responsible for the accreditation process. 2. Develop a clear communication plan to disseminate information to staff. B. Establish an Accreditation Steering Committee 1. Compose a multidisciplinary team. 2. Assign specific roles and responsibilities to committee members. III. Organizational Culture A. Cultural Assessment 1. Evaluate the current organizational culture. 2. Identify areas needing improvement for alignment with Joint Commission standards. B. Staff Training and Engagement 1. Develop a training program for staff on the importance of accreditation. 2. Implement mechanisms for continuous staff involvement and feedback. IV. Policies and Procedures A. Review and Update Policies 1. Conduct a comprehensive review of existing policies