Tips for an Effective Plan of Correction

When a deficiency is cited, the clock starts ticking. How you respond through your Plan of Correction can set the tone for your survey outcome—and your facility’s reputation. This week, we’re sharing practical tips to help you craft a PoC that not only meets regulatory requirements, but also drives lasting quality improvement.

Tips for an Effective Plan of Correction

When surveyors identify deficiencies, the way your facility responds can make all the difference. A strong Plan of Correction (PoC) not only satisfies regulatory requirements, but also demonstrates your facility’s commitment to quality care and continuous improvement. Here are some practical tips to help you develop an effective PoC:

1. Address Every Element of the Deficiency

Surveyors expect a complete response to each citation. Make sure your PoC answers the “five key questions”:

• • What will you do to correct the deficiency?
  • How will you prevent recurrence?
  • Who is responsible for implementing the corrective action?
  • When will the correction be completed?
  • How will you monitor compliance?

Leaving out even one of these can result in rejection.

2. Be Specific and Measurable

General statements like “staff will be re-educated” aren’t enough. Instead, describe exactly what education will be provided, who will receive it, how it will be delivered (e.g., in-services, one-on-one coaching), and how competency will be validated. Whenever possible, include measurable outcomes (e.g., 100% of staff will demonstrate proper technique by return demonstration).

3. Focus on Systems, Not Just Individuals

It may be tempting to attribute deficiencies to staff error, but surveyors want to see how your systems will change. Strengthening policies, updating procedures, improving documentation, and enhancing monitoring tools demonstrate proactive correction at the facility level.

4. Include a Realistic Timeline

Corrections must be timely, but also achievable. A rushed plan can set you up for failure. Be honest about what can reasonably be completed by the required date and ensure you have the resources to meet it.

5. Build in Ongoing Monitoring

Surveyors want to see how you’ll ensure compliance over time. This might include audits, observation rounds, or QAPI review. Describe the frequency of monitoring, who will conduct it, and how results will be tracked and acted upon.

6. Assign Clear Accountability

Each action step should have a designated person responsible—not just “the nursing department” or “administration.” Clear accountability increases follow-through and strengthens your credibility with surveyors.

7. Make It Sustainable

Your PoC should create lasting change, not just a quick fix until the next survey. Think about how to embed the corrective action into daily operations, staff orientation, and ongoing training.

An effective PoC tells surveyors, “We take this seriously, and here’s exactly how we’ve corrected the issue and ensured it won’t happen again.” By being specific, system-focused, and measurable, you not only achieve compliance but also strengthen your facility’s overall quality of care.

Next Steps:

• • Register to join Proactive’s Survey Prep & Understanding Post-Survey Elements series running weekly starting this week through October—including sessions devoted to responding to deficiencies.
  • Become a member of the Proactive Solutions Centers to access phenomenal survey preparation tools, up to date policies and procedures, on-demand training, and Plan of Correction templates for the top tags in the nation.
  • Contact Proactive for survey management support—including mock surveys, Plan of Correction development or implementation assistance, Directed Plan of Correction, or same day crisis support through our Virtual Consultation portal.

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