Corrective Action Process

Identification of Quality System Deficiencies

• A deficiency is defined as any unauthorized deviation from acceptable procedures or practices, a defect in an item, or failure to conform with a specified requirement.
• Deficiencies may be identified during the course of a formal agency audit or internal audit. Deficiencies may also be self-identified during the course of routine work.
• Deficiencies shall be documented immediately and reported to supervisory personnel in writing. The reports of deficiencies to supervisory personnel will serve as initial deficiency notices.
• Supervisory personnel shall forward initial deficiency notices to the appropriate Project Manager and lead QA staff. Lead QA staff shall determine whether or not deficiencies are significant conditions as defined in the TCEQ QMP, including cases in which deficiencies recur after having been identified and previously corrected. Project, program, and organizational managers may also determine whether deficiencies are significant conditions.
• Lead QA staff shall notify affected Deputy Directors, Section Managers, Grant and Program Managers, and the QA Manager of any significant conditions.
• If lead QA staff and project, program, or organizational management disagree as to the determination of significant conditions for a deficiency, any of the parties may appeal to the TCEQ QA Manager for resolution.

Planning and Implementing Corrective Actions

• With concurrence of affected lead QA staff, Project Managers or designees shall prepare a corrective action plan (CAP) to determine and document the following with regard to each deficiency:
• root cause(s);
• programmatic impacts;
• required corrective action(s);
• required corrective action(s) to prevent recurrence;
• means by which corrective actions will be verified as effective;
• means by which corrective action completion will be documented;
• timetable(s); and
• individual(s) responsible.
• Within 30 days of the initial deficiency notice, the project manager or designees shall submit forward copies of CAPs to supervisory and lead QA staff involved in implementing or monitoring corrective actions. Lead QA staff shall forward copies of CAPs concerning significant conditions to the affected Deputy Directors, Section Managers, Grant and Program Managers, and the QA Manager.
• Supervisory staff shall ensure CAPs are implemented effectively and in a timely manner. Lead QA staff may monitor the implementation of CAPs and shall advise the appropriate project and program manager if the plans are not implemented in a timely manner. In the case of significant conditions, the lead QA staff shall advise the appropriate Deputy Director, Section Manager, and the QA Manager if CAPs are not implemented in a timely manner.
• Depending upon program requirements, either the Project Manager or QA staff will notify affected management and the lead QA staff when corrective actions have been completed and verified to be effective, and that the associated CAP(s) can be closed. In the case of significant conditions, the lead QA staff shall advise the Project Manager, Program Manager, and appropriate Deputy Director, Section Manager, and QA Manager when corrective actions have been completed and verified to be effective, and that the associated CAP(s) can be closed.
• The current version of the TCEQ QA CAP template(Word) is available for download.
• For resources specific to TCEQ's National Environmental Laboratory Accreditation Program (NELAP), please visit the TCEQ Environmental Laboratory Accreditation webpage.