42 CFR §488.401 defines a Plan of Correction (PoC) as a plan developed by the facility and approved by CMS or the survey agency that describes the actions the facility will take to correct deficiencies and specifies the date by which those deficiencies will be corrected.
The facility should not wait until the survey has concluded and the CMS-2567 is received to begin writing a PoC. Development of the PoC should begin the day of exit based on information received from the exit conference and the facility team should immediately begin to work the plan. Adjustments to the PoC can be made as necessary once the final 2567 is received. Learn more about taking action in response to the CMS-2567, addressing each of the 5 elements of the PoC, and helpful tips for drafting an effective PoC…
Form CMS-2567 Statement of Deficiencies
The facility should receive Form CMS-2567 Statement of Deficiencies within 10 business days following survey exit (via email). Once received, the facility has 10 calendar days to submit an acceptable plan of correction to the Survey Agency. Submission of an acceptable PoC is required for all deficiencies of scope and severity Levels B through L.
Each deficiency cited will include:
- Regulatory reference – Survey data tag number; CFR (Code of Federal Regulation) or LSC (Life Safety Code) reference; Language from that reference which specifies the aspect(s) of the requirement with which the entity was noncompliant; Explicit statement that the requirement was “NOT MET”
- Deficient practice statement – Specific action(s), error(s), or lack of action (deficient practice); Outcome(s) relative to the deficient practice, when possible; Description of the extent of the deficient practice or the number of deficient cases relative to the total number of such cases; Identifier of the individuals or situations referenced in the extent of the deficient practice; Source(s) of the information through which the evidence was obtained
- Relevant findings: Illustrate the noncompliance with the requirement; Answers the questions – Who, What, Where, When and How
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 this related to a knowledge deficit?
- Is the problem isolated or discrete?
- 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.
- What the corrective action was
- Date of implementation
- 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.
- How the facility determined if other residents were affected by the alleged deficient practice (assessments/evaluations, observations, audits, interviews, report reviews, etc.)
- The date this was determined
- By whom
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
- Detail the measures/actions taken
- Policy reviews/revisions
- Systemic change, if needed, to prevent reoccurrence (based on root cause analysis)
- 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
- How the facility will ensure that all new staff receive the training/education
- Provide the dates of measures/actions and the titles of staff completing them.
- Detail the measures/actions taken
Element 4: Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
- How the corrective actions will be monitored (audit tools, interviews, record reviews, etc.)
- Frequency and quantity of monitoring
- How the results will be evaluated and by whom (monitoring method should have a measurable outcome/goal)
- 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.
- 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.
- The date of compliance for the deficient practice:
- cannot be a date on or prior to the survey exit date, and
- cannot be a date when action is being taken by the facility.
- The date of compliance for the deficient practice:
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. 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. 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 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).
- Daily stand-up meeting with management team to review PoC progress. Assign the PoC tasks for the day.
Daily stand-down meeting. Collect completed tasks and discuss any concerns. Prepare a Plan of Correction/Allegation of Compliance Book that contains the following:
- Copy of Plan of Correction
- Tab for each tag
- Section for all training and education
- Include all participants
- Include content and competency testing
- Section for any material that supports allegation of compliance
- Keep the book up to date and ready to provide to surveyors upon revisit
Have an All-Staff meeting to discuss the Statement of Deficiencies and Plan of Correction. Prepare staff for revisit, survey interviews/observations, etc.
Include a Disclaimer at the beginning of the PoC. Examples:
- This Plan of Correction constitutes this facility’s written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
- Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.
Make plans to join us in 2022 for the monthly webinar series Survey Success! beginning in January with a focus on improving survey outcomes through a deep dive review of deficiency trends and strategies for survey preparedness. Learn more and register at: Survey Success! Avoiding Top Citations – Proactive Medical Review
Contact Proactive for assistance in developing a PoC, implementing a Directed PoC or to schedule your 2022 mock survey.
