Q:
When does the state survey agency or CMS usually apply the remedy of a Directed Plan of Correction?
A:
A Directed Plan of Correction (DPoC) is a remedy that provides for directed action(s) from either the State or CMS Regional Office (RO) that the facility must take to address the noncompliance or a directed process for the facility to more fully address the root cause(s) of the noncompliance. A directed POC differs from a traditional POC in that the state, not the facility, develops the POC. Achieving compliance is ultimately the facility’s responsibility, whether or not a directed plan of correction is followed.
The DPoC is a Level 1 category of available remedies and can be used as an optional remedy for any deficiency cited at a scope and severity of D or higher. It is most often used with Infection Control related deficiencies that have resulted in a repeat tag, or other repeat deficiencies where the facility has been unable to achieve and maintain ongoing compliance, or systemic failures have been identified.
With repeat Infection Control deficiencies, the Directed Plan of Correction will frequently include the following:
- A Long Term Care Facility Infection Control Self-Assessment
- A Root Cause analysis for the systemic failure(s) that occurred that resulted in the non-compliance with F880
- Staff completion of assigned modules of the Nursing Home Infection Preventionist training available on the CDC website
- A log of the staff and their titles that have completed the training modules along with the date of completion for each required module
- A notarized letter on the facility’s letterhead from the administrator summarizing the circumstances in which the training was completed by the staff.
- A quality assurance plan for checking compliance with infection control prevention and surveillance on all shifts and weekends monitoring the cited infection control system(s)
In accordance with 42 CFR §488.402(f), the DPoC remedy is effective 15 calendar days from the date of the notice letter. Submission of the DPoC is required prior to the authorization of a revisit survey to determine compliance with the Federal Participation requirements.
Contact Proactive for assistance in implementing Directed Plans of Correction or for other survey management support.
Written By:
Janine Lehman, RN, RAC-CT, CLNC
Director of Clinical Services
Proactive LTC Consulting
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