Common Reasons Plans of Correction (PoCs) Are Rejected
Receiving a Statement of Deficiencies (CMS-2567) is stressful enough. Writing a Plan of Correction (PoC) that satisfies your state survey agency can be equally intimidating.
Under CMS regulations (42 CFR §488.401), a Plan of Correction is a written plan developed by the facility, and approved by CMS or the state survey agency, that describes the actions the facility will take to correct deficiencies with a specified date by which those deficiencies will be corrected.
While CMS establishes the basic requirements for a PoC, each state survey agency may have slightly different expectations regarding the level of detail required. With that said, a PoC that is accepted in one state may be rejected in another. But here’s the good news–most rejected PoCs fail for the same reasons—and they’re usually preventable.
Common Reasons Plans of Correction Are Rejected
Some of the most frequent reasons a PoC is rejected include:
-
- Failure to identify and address the root cause of the deficient practice.
- Failure to address all five required elements.
- Corrective actions that focus only on the cited resident(s) instead of making systemic improvements.
- Vague or nonspecific corrective actions.
- Weak or incomplete monitoring plans.
- Failure to identify who is responsible for each action.
- Unrealistic or missing completion dates.
- Arguing with or disputing the deficiency within the PoC.
- Omitting the signature of the administrator or authorized representative.
Before You Begin Writing
Before writing the PoC, spend time analyzing the deficiency and determining why it occurred.
- Analyze the Statement of Deficiencies
Carefully review every example included under each deficiency.
Remember:
-
- A single F-tag may contain multiple deficient practices.
- Each cited issue requires its own corrective action.
- Pay close attention to patterns identified by surveyors rather than focusing only on the specific resident examples.
- Complete a Root Cause Analysis
One of the greatest mistakes facilities make is treating the symptom rather than correcting the underlying problem.
Ask questions such as:
-
- What process failed?
- Were policies incomplete or outdated?
- Were staff expected to perform a specific task, but failed to do so?
- Was there a knowledge or competency deficit?
- Was this an isolated incident or evidence of a system-wide problem?
- What allowed this deficiency to occur?
Example: If a resident developed a pressure injury and weekly skin assessments were missed, the root cause may not simply be “staff forgot.” The real issue could be the absence of an effective tracking system, inadequate nurse education, or lack of supervisory oversight. Addressing only issues around the specific resident’s wound care does not prevent the deficiency from recurring.
The Five Required Elements of Every Plan of Correction
- Correct the Resident(s) Affected
Describe exactly what corrective action was taken for the resident(s) identified in the CMS-2567.
Include:
-
- Specific interventions completed.
- Dates the corrective actions occurred.
- Titles of the staff members completing the actions.
Example: “On July 8, 2026, the Wound Care Nurse completed a comprehensive skin assessment, updated the resident #4’s care plan, and notified the attending physician of findings.”
- Identify Other Residents Who May Be at Risk
Explain how the facility identified other residents who could potentially be affected by the same deficient practice.
Examples include:
-
- Resident assessments
- Record reviews
- Audits
- Observations
- Staff interviews
Include:
-
- Dates completed
- Who performed the review
- How residents were selected
Avoid vague statements such as: “All residents are at risk.” Instead, explain how you determined which residents were potentially affected.
Example: “Between July 8 and July 10, 2026, the Director of Nursing audited the medical records of all residents requiring weekly skin assessments to verify assessments were completed as ordered. Any resident identified as not having a current skin assessment received a comprehensive skin assessment by their assigned licensed nurse during the audit period. Findings were documented in the medical record, and any newly identified skin concerns were reported to the attending physician, with care plans updated as indicated.”
- Implement Systemic Changes
This section explains how the facility will prevent the deficiency from happening again.
Examples of possible systemic changes include:
-
- Revising policies or procedures.
- Updating workflows or documentation processes.
- Implementing new tracking systems.
- Providing focused staff education.
- Adding competency validation or skills check-offs.
- Incorporating education into new employee orientation.
If education is provided, include:
-
- Topics covered.
- Method of education.
- Who conducted the training.
- Required attendees.
- Dates completed.
- How staff absent during training (vacation, FMLA, PRN, agency, etc.) will receive the education before returning to resident care.
Remember that education alone is rarely enough. Survey agencies expect to see changes to the system—not simply retraining staff.
Example: “Effective July 15, 2026, the facility revised the Weekly Skin Assessment policy to clarify assessment frequency, documentation requirements, and nurse responsibilities. A recurring Weekly Skin Assessment treatment was added to the eTAR for each resident requiring weekly skin assessments. Assigned licensed nurses are responsible for completing the comprehensive skin assessment and signing off on the treatment in the eTAR upon completion. Unit Managers will review eTAR treatment compliance routinely to ensure assessments are completed as scheduled and address any missed treatments promptly. Licensed nurses received education on the revised process, including assessment expectations, documentation requirements, and timely physician notification of newly identified skin concerns. Staff competency was validated through documentation review and direct observation. This education will also be incorporated into orientation for all newly hired licensed nurses.”
- Monitor to Ensure Sustained Compliance
This is often the weakest section of many PoCs.
A strong monitoring plan clearly explains:
-
- What will be monitored.
- How monitoring will occur (audit tool, observations, interviews, chart review, etc.).
- How many records or residents will be reviewed.
- How often monitoring will occur.
- Who is responsible for supervising the monitoring process.
- How results will be reported to the QAPI Committee.
- What corrective action will occur if compliance falls below expectations.
Some state agencies also expect the titles of QAPI Committee members to be included.
Example: “Beginning July 21, 2026, the Assistant Director of Nursing will run an electronic audit report weekly for four weeks, then monthly for two months to identify all residents requiring a weekly skin assessment, and will verify the assessment was completed and signed off in the eTAR. For any resident identified as having a missed or incomplete assessment, the ADON will review the medical record to determine the cause, verify completion of the skin assessment, and ensure any newly identified skin concerns were documented, reported to the physician, addressed through appropriate interventions, and reflected in the resident’s care plan. Audit findings and compliance trends will be reviewed at the monthly QAPI meeting. If compliance falls below 95%, the Director of Nursing will conduct a root cause analysis, implement targeted corrective actions, and increase the frequency of monitoring until sustained compliance is achieved.”
- Include a Realistic Completion Date
Every PoC must include a specific completion date.
Avoid terms such as:
-
- Immediately
- Ongoing
- As needed
Instead, provide an actual calendar date.
The completion date must:
-
- Meet your state agency’s submission requirements (generally within 60 days of the survey exit date).
- Allow enough time for every corrective action to be completed.
For example, if the final staff education session occurs on July 20, the earliest completion date would be July 21—not July 20.
Avoid Arguing Within the Plan of Correction
One of the quickest ways to have a Plan of Correction rejected is to dispute the deficiency within the document. If your facility disagrees with the citation, consult legal counsel regarding appropriate disclaimer language. Many facilities use the phrase “alleged deficient practice” throughout the PoC while still describing the corrective actions to be taken. Formal disagreement with one or more deficiencies should be pursued through the Informal Dispute Resolution (IDR) process—not within the Plan of Correction itself.
Don’t Forget the Signature
Sometimes a Plan of Correction is rejected for a reason that has nothing to do with its content. Survey agencies require that the first page of the CMS-2567 be signed and dated by the facility administrator or another authorized representative. An unsigned or undated Plan of Correction may be returned without review, delaying acceptance and potentially placing the facility at risk of missing required submission deadlines.
Before submitting your PoC, complete one final quality check to ensure:
-
- The first page of the CMS-2567 is signed by the administrator or another authorized representative.
- The signature is dated.
- All pages of the PoC are included.
- The submission meets your state agency’s instructions and deadline.
This simple final review can prevent an unnecessary rejection after you’ve invested significant time developing a thorough Plan of Correction.
Final Thoughts
A successful Plan of Correction is much more than a promise to “re-educate staff.” Survey agencies want evidence that the facility identified the root cause, corrected affected residents, implemented meaningful system changes, and established an effective monitoring process to ensure the deficient practice does not recur. Before submitting your next PoC, ask yourself one final question: If another surveyor walked into the building six months from now, would the changes described in this Plan of Correction still be in place?
If the answer is yes, you’re likely on the right track.
Next Steps:
- Make Proactive your partner in survey success. Through mock surveys, support for developing and implementing effective Plans of Correction and ongoing partner plan consultation on a facility specific work plan, our team provides the boots on the ground assistance, expert guidance and resources for survey success. Contact us today to learn more about partnership options.
- Reduce deficiencies through a proven program of advance survey preparation with the Proactive Survey Ready Toolkit
References
https://proactiveltcexperts.com/effective-plans-of-correction/
Written By:
