A Plan of Correction (PoC) provides an agency or facility the opportunity to demonstrate steps taken to appropriately address issues noted in a Statement of Deficiencies. The Statement of Deficiencies is a state or federal report that provides a detailed description of deficient practices based on the recent survey of a facility/agency. The lower left hand corner of the report will either show “FORM CMS – 2567” (Federal report) or “State Form” (State report).
All Statement of Deficiencies and Plans of Correction are considered public documents; therefore, releasable to any person or entity upon request.
Submission Example / Directions
| Column 1 | Column 2 | Column 3 | Column 4 | Column 5 |
|---|---|---|---|---|
| ID Prefix Tag | Summary Statement of Deficiencies | ID Prefix Tag | Provider’s Plan of Correction | Completion Date |
| Tag Number | Regulation requirement is spelled out here, followed by the evidence to support the decision of noncompliance. | You will either: Write you PoC here OR Refer to your PoC which was submitted as a separate document | Tag Number | Write your PoC completion date |
Column 1 – “ID Prefix Tag”
This is the number associated with the regulation.
Column 2 – “Summary Statement of Deficiencies”
This section has 3 basic components:
- The regulation – The regulation is quoted as it appears in either the Federal or State set of regulations for the provider type.
- The deficient practice statement – This statement begins with the words “Based on”. The statement summarizes the types of findings (observation, interviews, records review, etc.) used to document the deficient practice. It is followed by a summary statement on how the regulation was not met.
- The findings – These are the separate points that the surveyor noted when evaluating your regulatory compliance. There may be multiple findings for one regulation.
Column 3 – “ID Prefix Tag”
Repeat of Column 1.
Column 4 – “Provider’s Plan of Correction”
This section is where you either write your PoC, or refer to your PoC which was submitted as a separate document.
Column 5 – “Completion Date”
This is the date on which you will have completed your action plan and you expect to be back in compliance with the regulation. Only one date for each tag should appear in this column. This date should be within 60 days of the survey exit date.
Submitting a Plan of Correction
There are three (3) distinct sections to a PoC. Each section must be addressed for a PoC to be acceptable.
Section A
- State what you did to immediately address the issue for each individual (patient or staff) or each area that was impacted by the deficient practice. · Include the activity and responsible position/job title.
- Each finding must be addressed.
- If you could not fix the problem for the individual impacted, then just say so and explain why. Examples of deficiencies that cannot be corrected retrospectively:
- If a patient was required to have a comprehensive history and physical 30 days prior to a procedure, but the patient already had the procedure and was discharged.
- If a comprehensive assessment was not completed within the required timeframe.
Section B
- Determine the processes that lead to the deficiency. This should include a review of: policies & procedures; training to determine if staff has received adequate instruction; QAPI practices.
- Develop and state your action plan to “fix” the deficient practice so it does not reoccur. For example, you may have to: write/revise a policy and provide training to staff to implement the action plan.
- Reference and provide supporting evidence that you completed your action plan. For example, label attachments/exhibits with an identifier (i.e. Exhibit A) and reference the attachment/exhibit identifier in the text of your PoC.
Section C
- What quantitative measurements will you put into place to determine if your action plan was successful? Putting an action into place to fix a problem is not effective unless you follow up to make sure that the action was successful & solved the problem.
- You may need to develop a tool to monitor the improvements in your deficient practice. Always keep in mind that regulations are minimum requirements and the compliance expectation should be 100%.
- Pick your sample carefully. The sample must be big enough to give you the data you need. For example, if you are looking at issues with wounds, do not pick a sample from total admissions. Pick a sample from admissions with wounds.
- List the position of the staff member that will monitor the success of your action.
What not to include in a PoC
- Do not include the names of patients or employees. All patients and employees are given identifiers during the survey. Use those identifiers in your PoC. If including an employee not identified in the Statement of Deficiencies, use a job title.
- Do not put more than one date for each tag in Column 5. Multiple dates may be included in the body of your PoC in Column 4 but Column 5 is for the final date on which you expect to be in compliance with the regulation.
- Do not simply write, “The deficiency has been corrected”. This is not acceptable.
Checklist for submitting a PoC
- The Provider Representative’s signature is required on the first page of the CMS-2567 for the PoC. If you submit your PoC as a separate attachment, you must attach the signed first page of the CMS2567.
- Make sure that you have addressed each deficiency.
- Make sure that the PoC is written in the format prescribed and that any & all additional pages are attached.
- Make sure that there is one completion date for each tag in Column 5.
- If you have referenced attachments/exhibits in your PoC, make sure they are all included in your PoC submission. If an attachment/exhibit is referenced multiple times, only one copy needs to be submitted.
- Send via regular mail or electronically. If sending electronically, respond to all individuals that were copied on the e-mail in which you received the Statement of Deficiencies.
- You have 10 calendar days to complete and submit your PoC regardless of whether you submit the PoC via mail or electronically.
PoC Frequently Asked Questions
What do you mean by individual or area impacted?
This may be a patient, an employee, a medical record, a wall or anything else that is identified by the surveyor.
What is the time frame to take corrective action?
Corrective action for Section A must occur immediately or as soon as possible. This is particularly true for patient care issues and patient records. It is not acceptable to wait until the next time something is due or scheduled. System changes and regulatory compliance must be accomplished within 60 days of the exit date of the survey.
What do you mean by a system change?
Once you have determined the processes that lead to the deficiency, these are steps that you take with your employees, policy and procedure implementation, and educational offerings that you institute to avoid a recurrence of the deficient practice.
Sometimes several tags contain the same findings, can I just copy the same answer over and over?
Rarely. The same problem frequently supports different regulatory violations. Each regulation is different. You are expected to fix the problem in the context of that regulation. For example, if one of the regulations cited is about governing body, system changes that fail to include a reference to the governing body would not be acceptable.
Do I have to indicate that an employee was disciplined or terminated?
When an agency/facility feels that the policies and procedures are sound, and the issue that led to the deficient practice was noncompliance, you are encouraged to indicate “supervisory intervention” versus disciplined or terminated.
What if my corrective action is greater than 60 days?
There are some (although rare) instances where certain types of corrective action cannot be completed in 60 days. One example might be construction. When this occurs, your response should identify the time line for the planned activity (construction) and the activities (planning, bids, contracts, purchase order, etc.) that will occur within the 60 days to establish compliance.
What do you mean by evidence?
Evidence is the documentation of the action you took and may be in the form of: new policies; revised policies; lesson plans for educational offerings; attendance sign-in sheets; meeting minutes; purchase orders; contracts; new or revised forms; etc. If you highlight (preferably in yellow) the information that explains your actions, it is helpful in allowing the OHFLC to focus their attention.
What is an appropriate sample size?
This may change with each deficient practice. This will be determined by you dependent upon the scope and severity of the problem and must be adequate enough to allow you to determine if you fixed the problem. A minimum sample size of 10% is expected. Make sure that your sample is reflective of the deficiency cited (if the deficiency cited was related to wound care, then your sample should be of patients requiring wound care, not the entire patient population).
How long do I have to monitor or measure?
You have to monitor or measure until you determine that you fixed the problem or until you determine that your current plan did not work and you need to try something else. An example of how monitoring/measuring might be conducted appears below:
- Monitor the sample for the identified deficient practice daily until you consistently reach 100% success over 3 consecutive evaluations. THEN…
- Decrease monitoring your sample to three times a week until you consistently reach 100% success at 3 consecutive evaluations. THEN…
- Decrease monitoring your sample to one time a week until you consistently reach 100% success over 3 consecutive evaluations. FINALLY…
- Measure one more time a month later. If you still reach 100%, you can conclude that you have successfully addressed the problem.
What is a measurement tool?
A measurement tool is a concrete method used to document, evaluate and report the data collected during your evaluation. It can be a newly created form, an existing form, a report, meeting minutes, a memo or an email. Verbal communication is not acceptable as a measurement tool.
Can I measure monthly or annually?
Not initially. If the changes you made did not work, the deficient practice will continue to occur for a month or a year before you know that your change was not successful. This is not acceptable.
How do I document staff education as it relates to the deficient practice?
Be specific as to who is being educated (all staff; all nurses; all physical therapists, etc.); include lesson plans; include staff attendance records; identify who provided the education, including their qualifications.
