After the Survey: Tips On Writing an Effective Plan of Correction

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 survey agency. It 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 the survey concludes and the CMS-2567 form arrives is not advisable. Begin drafting the PoC on the day of exit, using insights from the exit conference. In addition, the facility team should 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 plan of correction must address how you are correcting your non-compliance with that specific regulatory requirement.
   • Deficient Practice Statement: The CMS-2567 will describe specific actions, errors, or lack of action constituting the deficient practice. Each of these elements should be addressed through your corrective action plan.
4. Submission Timeline: After the 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 Survey Agency. This requirement applies to deficiencies falling within scope and severity Levels B through L.

Taking Action on the 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 a Root Cause Analysis 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?
        • Is the problem system-wide or systemic?

Plan of Correction Requirements

The Plan of Correction consists of 5 Elements:

• Element 1: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.

• 1. What the corrective action was
  2. Date of implementation
  3. Who was responsible for making the corrections (position title)

• Element 2: Address how the facility will identify other residents having the potential to be affected by the same deficient practice.

• 1. How the 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.
  3. By whom
  4. It is not acceptable to state “All residents have the potential to be affected.”

• Element 3: Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.

• 1. Detail the measures/actions taken.
  2. Policy reviews/revisions
  3. Systemic change, if needed, to prevent reoccurrence (based on root cause analysis)
  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 the training, training date, required attendees.
  5. How the 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 the facility plans to monitor its performance to make sure that 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 the results will be evaluated and by whom (monitoring method should have a measurable outcome/goal)
  4. How and when will findings be reported to the QAPI committee. Note: Depending on the State or CMS Region, the facility may be required to 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. The date of compliance for the deficient practice: cannot be a date on or prior to the survey exit date.
  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 that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely.
  4. The plan of correction 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 is:

• • • A legal document
    • A formal statement informing the state and federal agency 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 Quality Assessment & Performance Improvement 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? Join us for the Survey Prep and Understanding Post-Survey Elements webinar series continuing weekly through April and May. Contact Proactive for assistance in developing or implementing a survey readiness plan or for help in drafting a Plan of Correction.