A plan of correction (POC) is a plan developed by the facility and approved by CMS or the state survey agency that clearly describes the actions the facility will take to correct deficiencies cited during a survey and specifies the date by which those deficiencies will be corrected. Consider these tips when developing your POC:
Timing
Use the information received during the exit conference to immediately begin to work on the PoC, rather than waiting for the arrival of the Statement of Deficiencies (form CMS-2567). Adjustments to the POC can be made once the Statement of Deficiencies has been received.
The facility should receive the Statement of Deficiencies within 10 business days following survey exit. Once received, the facility has 10 calendar days to submit an acceptable PoC to the state survey agency.
Content
Thoroughly read the Statement of Deficiencies. Multiple issues can be written under one tag. Remember that each issue requires corrective action. When determining actions required to correct the deficient practice, a root cause analysis should be conducted to determine what caused each deficient practice to occur. The following should be considered:
- What systems were lacking or incomplete?
- Was there something the staff should have been doing or doing differently?
- Is the deficient practice related to a knowledge deficit?
- Is the problem isolated or distinct?
- Is the problem system-wide or systemic?
There are five elements that must be addressed when developing a plan of correction.
- Element 1: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice
- What action was taken?
- What was the date the action was implemented?
- Who was responsible for implementation?
- Element 2: Address how the facility will identify other residents with the potential to be affected by the same deficient practice.
- How did the facility determine other residents were or were not affected by the deficient practice?
- What was the date the determination was made?
- Who was responsible for making the determination?
- Element 3: Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur
- Give details of the measures/actions taken
- Policy and procedure revisions
- Systemic changes made based on identified root cause
- Staff education
- Provide the dates of completion for each measure put in place and the title(s) of staff completing them
- Give details of the measures/actions taken
- Element 4: Address how the facility will continue to monitor for compliance.
- Who will be responsible for continued monitoring?
- What tools or actions will be taken to monitor?
- What will be the frequency of monitoring?
- How will the facility evaluate the results to ensure sustained compliance?
- How and when findings will be reported to QAA committee?
- Element 5: Dates when the corrective action will be completed.
- The completion date cannot be prior to survey exit and all actions must be in place and complete
- The corrective action completion date must be acceptable to the state
- Element 1: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice
Join Proactive Medical Review on December 6th for the final session of our 2022 webinar series Survey Success! Avoiding Top Citations where we will discuss Post Survey Activities: Developing an Effective Plan of Correction and the IDR process. Missed the series? Sessions are available for purchase through the Proactive Shop Survey Success Series Recordings.
Contact Proactive for assistance in developing a Plan of Correction or to schedule a mock survey for 2023.
