Understanding Basic Components: A Plan of Correction This presentation addresses the basics for a Plan of Correction – in broad strokes. Specific situations may require more in depth planning.

Objectives Understand the need for a clear and concise POC Identify the basic components of a POC Write an acceptable POC (SOM Chapter 7) Except in cases of past noncompliance, facilities having deficiencies (other than those at scope and severity level A) must submit an acceptable plan of correction before substantial compliance can be determined.

Why is a POC Needed? Provide a detailed outline of the facility’s plan to achieve and maintain compliance Assists surveyors in determining the status of implemented corrective actions Utilized by surveyors in revisit offsite preparation In cases of non-immediate jeopardy, a plan of correction must be submitted within 10 calendar days from the date the facility receives its Form CMS-2567.

Why is a POC Needed? “In accordance with Section 7317 of the State Operations Manual, the purpose of a post survey revisit is to re-evaluate the specific care and services that were cited as noncompliant during the original survey.” Because your Plan of Correction will be scrutinized during the revisit – it becomes very important to have a clear and concise Plan of Correction.

The SA reviews the POC for: Appropriateness Legibility Completeness The POC must be realistic and specific. This includes the Who will be responsible, How the corrective action will be accomplished, When, how Monitored and for how long, where the documentation will be kept and Where reported. Integrating your Plan of Correction with the Facility’s QA Program is always good. Completeness would include data about your QA Committee. Who is on the Committee as well as how often the committee meets. Is the monitoring ongoing or for a specific length of time?

What must a POC have to be complete? Entered on the right side of Form 2567 opposite the deficiency Include a planned action to correct the deficiency Realistic date when the deficiency is corrected Signed and dated by the administrator Again – remember to be specific as to Who, How, When and Where to accomplish your plan.

An acceptable POC must: “Address what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.” Monitoring is very important – give thought to Who will monitor, How will the monitoring be done and How often - be specific. Where the results of the audits are documented. How will this be integrated into your QA program.

An acceptable POC must: “Address how the facility will identify other residents having the potential to be affected by the same deficient practice.” Again – look at how you plan to audit and monitor. What is your plan? Do you have in mind specifics of Who, How, When, and Where?

An acceptable POC must: “Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.”

Examples of Measures/Systemic Changes could be: Policy Revision Procedure (new or revised) Monitor and Interface with QA Studies Specific In-Service New Staff Orientation & regular staff in-service schedules Remember: you must be specific! Dates & Times for in-service along with sign-in sheets. Who did wrote the Policy Revision or Procedure - as well as the date and time. Monitoring specific data and data about your QA Committee (Who makes up your committee? How often does the QA committee meet? How often will the monitoring results be reported – short term or ongoing?

Example: “When new lab work is ordered, the charge nurse on each unit will take off the order, enter it in the log book and contact the lab rep.” “An in-service on lab protocol was provided to all nurses on 3/14/07 by the DON. This in-service is now part of new hire orientation and during annual staff development training.” Remember – In the POC whenever there is training you should always note Who is teaching, When occurs (date/time) and How Often. Be specific. The same information for monitoring.

An acceptable POC must: “Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved & sustained. This plan must be implemented & the corrective action evaluated for its effectiveness. The POC is integrated in the QA system.” Who will accomplish this? How often (date/time). Who will keep the documentation. Information will be needed regarding your QA Committee – Who makes up the Committee? How often does you QA Committee meet? What are your time frames for monitoring and evaluating for effectiveness.

Example: “Weekly the DON, ADON, or Unit Supervisors, will review 5 charts on each unit to determine who took the orders off, check the lab log for a corresponding entry, determine if lab has been contacted. Don will interview nurses with emphasis on new hires to determine protocol understanding. This documentation will be kept in the DON’s office. In this example – the 5 questions of How, Who, What, When and Where are answered. In your POC remember to be specific with date/time for any audit and where/when and how integrated into your QA program

An acceptable POC must: “Include dates when corrective action will be completed.” The corrective action completion dates must be acceptable to the State. (Chapter 7/SOM) Facilities are ultimately accountable for their own compliance to their Plan of Correction (POC). Always be specific!

Review of components for POC: Address how corrective action will take place for those residents affected by the deficient practice. Address how the facility will identify other residents having the potential to be affected by the deficient practice.

Continued Review: Address what measures will be put into place or systemic changes so the deficient practice will not recur. Indicate how the facility plans to monitor its performance. Include dates when corrective action will be completed.

Remember… The facility is ultimately accountable for their own action compliance. It is important to have a clear and concise POC that covers: 1. Who is responsible for completing the action & documentation 2. Timeline for the action is be accomplished 3. How the action is to be monitored Timelines for POC include how often and for how long. Remember be specific as to Who, How, When, Where