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After the Survey: Writing an Effective Plan of Correction

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Let’s delve into what a Plan of Correction (POC) entails. According to, 42 CFR §488.401 a POC is a plan developed by the facility and approved by either CMS or the SA that outlines the actions the facility will take to rectify deficiencies and specifies the date by which those deficiencies will be corrected.

 

 Key Strategies for Success:

  1. Start Early: Waiting until survey concludes, and the CMS-2567 form arrives is not advisable. Begin drafting the POC on the day of exit, using insights from exit conference, & promptly initiate needed corrective actions.
  2. Flexibility:Adjustments to the POC can be made once the final CMS-2567 report is received. Flexibility is essential to tailor the plan effectively.
  3. Addressing Deficiencies: When responding to deficiencies, consider the following elements:
    • Regulatory Reference: The CMS-2567 will include the survey data tag number, relevant CFR (Code of Federal Regulation) or LSC (Life Safety Code) reference, and language specifying the noncompliant aspect. Your POC must address how you are correcting non-compliance with that specific regulatory requirement.
    • Deficient Practice Statement: The CMS-2567 will describe specific actions, errors, or lack of action constituting deficient practice. Each element should be addressed in the corrective action plan.
  4. Submission Timeline:After survey exit, the facility should receive the Form CMS-2567 Statement of Deficiencies within 10 business days (via email). Within 10 calendar days of receipt, an acceptable POC must be submitted to the SA (requirement applies to deficiencies falling within scope and severity Levels B through L).

 

Taking Action: CMS-2567

Analyze the Statement of Deficiencies:

  • Thoroughly read every example cited.
  • Multiple issues can be written under the citation for one tag.
  • Each issue requires corrective action.
  • Perform Root Cause Analysis (RCA) to determine why each deficiency occurred.
    • What systems were lacking or incomplete?
    • Was there something that staff should have been doing but were not?
    • Is the issue related to a knowledge deficit?
    • Is the problem isolated or discreet? System-wide or systemic?

 

Plan of Correction Requirements

The POC consists of 5 Elements:

  • Element 1: Address how corrective action will be accomplished for residents found to have been affected by the deficient practice.
    1. What the corrective action was & the date of implementation.
    2. Who was responsible for making corrections (position/title).
  • Element 2: Address how facility will identify other residents having potential to be affected by same deficient practice.
    1. How facility determined if other residents were affected by the alleged deficient practice (assessments/evaluations, observations, audits, interviews, report reviews, etc.)
    2. The date this was determined & by whom.
  • Element 3: Address what measures will be put in place or systemic changes made to ensure the deficient practice will not recur.
    1. Detail the measures/actions taken.
    2. Policy reviews/revisions completed, if appropriate.
    3. Systemic change, if needed, to prevent reoccurrence (based on RCA).
    4. Staff training/education- include specific content of information, training/education method, results of training (written post-test or skills checkoff), who is responsible for conducting training, training date, required attendees.
    5. How facility will ensure that all new staff receive the training/education.
    6. Provide the dates of measures/actions and the titles of staff completing them.
  • Element 4: Indicate how facility plans to monitor its performance to make sure solutions are sustained.
    1. How the corrective actions will be monitored (audit tools, interviews, record reviews, etc.).
    2. Frequency and quantity of monitoring.
    3. How results will be evaluated & by whom (monitoring method should have measurable outcome/goal)
    4. How & when will findings be reported to QAPI committee, list titles of QAPI team members.
    5. Actions to be taken if results indicate desired outcome/goal is not being achieved or maintained.
  • Element 5: Include dates when corrective action will be completed.
    1. Date of compliance for deficient practice: cannot be a date on or prior to survey exit date (unless Past Non-Compliance (PNC)).
    2. The corrective action completion dates must be acceptable to the State. If the plan of correction is unacceptable for any reason, the State will notify the facility in writing. If the plan of correction is acceptable, the State will notify the facility by phone, e-mail, etc.
    3. Facilities should be cautioned they’re ultimately accountable for their compliance, & responsibility is not alleviated in cases where notification about acceptability of the POC is not made timely.
    4. The POC will serve as the facility’s allegation of compliance. SOM Chapter 7- 7317 Acceptable Plan of Correction.

 

Plan of Correction Tips

When writing a POC, keep in mind that it’s:

  • A legal document.
  • A formal statement informing state & federal agencies of actions taken to correct deficiency.
  • Is publicly posted- do not use staff names, only titles.
  • Hold daily meetings until the survey team has determined compliance (via desk review or on-site visit).

Remember, an effective POC integrates corrective measures into the organization’s QAPI program. By adhering to these guidelines, facilities can achieve an acceptable plan of correction.

Would your team benefit from more survey readiness and response insights? Call Qsource for assistance in developing or implementing a survey readiness plan or if the facility requires assistance with drafting a POC; we can help!

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