Writing an Acceptable Plan of Correction

PHEW! You made it through another annual survey, but unfortunately you weren’t left unscathed. The exit interview could have gone a little better, but since you are aware of other issues that they didn’t uncover, you are glad to get through it with just a few small tags. Has anyone ever been there before? It’s hard to get a “perfect survey”, and few surveyors will consider one observation of an issues as “substantial compliance”, so how do you respond to the inevitable statement of deficiencies that will be coming? Let’s take a look at how to react to your survey findings and how to write an acceptable plan of correction. I'll be mostly addressing things from a nursing standpoint, but the general principles are applicable to life safety citation as well.

I know you have all kinds of ideas already about how you are going to proceed to “correct” the issues that were discussed in the exit conference, but slow your roll… you’re going to want to see exactly how the citation is written before you “respond”. The survey team has 10 business days to get the 2567 to the facility, and they usually take all of the days allotted to them. Remember, those are BUSINESS days… Monday – Friday. So, if your survey ends on Thursday the 14th, you can expect to be waiting two full weeks for your report to be available to you in the EIDC on the 28th.

THE WAITING GAME

There are a few things you can do to get the process started while you’re waiting for your report: prepare for the in-servicing that you know will need to be done and complete chart auditing and review policies and processes as needed.

You’ll generally know what you will need to address and with whom based on the exit conference. However, there may be details you will want to add to in-servicing that you won’t be aware of until the statement of deficiencies is available. For now, prepare education materials and plan for hands-on observations that may need to be done. Formally address issues with individual staff if there were concerns noted or observed by surveyors that led to the citation. By “formally”, I mean it should be documented. Call it what you want… individual in-service, written verbal warning, written warning… but it is best to show that you corrected the issue with them separately and timelier than the general in-servicing being done.  

You may need to review policies and make adjustments in processes if that was the root of a concern. Remember to keep things simple and methodical; it will make it easier for staff to understand or follow and, more likely, increase compliance.

You can also correct the issues noted in the cited residents’ charts if it’s something you can correct. Obviously, if it’s stuff that needed to be done in the past and it wasn’t done, you don’t have a time machine to right those wrongs. You can only fix it now and move forward.

You will need to audit the charts of residents with like diagnosis, orders, care needs or conditions as those cited as examples in the deficiency. You should be auditing to ensure more residents are not being affected by the concern that arose in the survey findings. Keep track of the charts/residents that were reviewed and when they were done. You don’t have to be fancy. You can simply mark up a census listing and make notes in the margins if that works for you. Using an audit tool can be helpful if you need something more organized to keep you on track. If the same issues that were noted during the survey are noted in these charts, correct them.

THE DAY OF RECKONING

Well, those 10 business days went by quickly and now your 2567 is in the EIDC. You’ll receive an email notification that it has arrived if you are listed as a recipient of notifications in the system. Now you have 10 calendar days to fashion your response and enter it into the EIDC. So… how did you do? When you log into the EIDC and open the communication, you’ll see how many citations you received, the F-tag they fall under and the scope and severity at which they were cited. If you have any citations listed as past non-compliance or at a scope and severity level A, you won’t need to do a POC for those tags. All other tags will require a POC.

As you read through the issues, you want to focus on what the SPECIFIC issue cited was. You will want to narrow your focus of the POC to THAT issue. When you are reviewing the concern that was cited, you may find other issues or other breakdowns in the process. You can address those issues on their own, but we are going to leave those out of the POC.

When you are writing the POC, only address the concern that is reflected in the 2567. Make your POC as simple and basic as possible. You only have to address the concern they identified. You can go above and beyond and address other issues you find, but you don’t want to include that detail in the POC. When they come for resurvey, they will review people who were or could have been or now be affected by the deficient practice to ensure the issue has been corrected.

WRITING THE POC

So how do you write the actual POC?

First, you’ll start with an entry position statement discussing how you are completing the POC as a requirement and not because you agree with the determinations enclosed. I’m sure your facility has a good version to use that will probably sound like you are speaking legalese. You’ll end this section with your allegation of compliance date. This is the date by which the facility states it will have all the deficiencies corrected. The date cannot precede the survey exit date and cannot be later than 50 days after the last day of the survey.

Let’s consider some things when choosing this date:

1. Make sure you leave time between your alleged date of compliance and

the last date to be compliant before penalties are imposed. (That date will be found in the letter that accompanies the 2567.)

2. Give yourself a few weeks of auditing to feel confident that processes are in place and being followed.

3. Don’t choose a Friday! They can show up for resurvey any day after the allegation of compliance date, and you don’t want it to be bright and early Monday morning, before you’ve had an opportunity to make sure things didn’t fall apart over the weekend. Choose a Tuesday or Wednesday as your date of alleged compliance. This gives you time to audit on a Monday to make sure things were still in place over the weekend.

Now we get into addressing the F-tag that was cited. Again, be sure to read and only address what was actually cited in the deficiency. You may be addressing additional things in reality, but we only need to respond with how we are addressing the specifics identified in the citation.

There are 4 parts to addressing the concern that was noted:  

1.     Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.     What did you do to fix the issue identified. Be sure to reference the residents affected by their resident identifier when responding. If you corrected the issue during the survey/following the observation, state that in your POC.

2.     Address how the facility will identify other residents having the potential to be affected by the same deficient practice. What will you audit to see if there are others out there who could be affected. If it was an observation, address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. What are you going to do to prevent reoccurrence. Consider who else needs to be addressed or in-serviced to prevent further observation of the issue.

3.     Identify the measures the facility will take or systems it will alter to ensure that the problem does not recur. Be specific with the approach, including the details of who, what, when, how and other interrogatives as needed. You may wish to consider use of external agencies or independent consultants for training, or partnering with such external agencies as the ombudsman’s office depending on the content or level of the citation.  

4.     Indicate how the facility plans to monitor its performance to make sure there isn’t a reoccurrence of the issue and that solutions are sustained. What QA are you going to do.          

Each time you talk about a task or action to be done as part of the POC, ask yourself ‘who will be doing it’, ‘what will they be doing’, ‘who it’s being done for’, and ‘when will it be done by’. Your date can be any time before the allegation of compliance date, but it can’t be after.

PUTTING IT ALL TOGETHER

Let’s try a simple example to show you what I mean; for this example, we’ll say that the alleged compliance date is 4/20/24…

The citation: (they’ll quote the F-tag from the SOM of what compliance entails and then list the deficient practice) … The facility failed to meet the requirements as evidenced by: During the dressing change observation with resident #25, RN #5 did not wash her hands after removing and discarding the old dressing, before putting on clean gloves to dress the wound.

Response: (remember you’d have your intro statement first, and then get into the root of the POC here)

Resident # 25 had no negative outcomes as a result of the observation made by the surveyor. RN # 5 was in-serviced by the DON regarding the proper technique for completing a clean dressing change, including washing of hands when soiled gloves are removed, on 3/15/24.

All nurses will be in-serviced by the DON regarding the proper technique for completing a clean dressing change, including washing of hands when soiled gloves are removed, by 3/27/24.

The DON/designee will conduct dressing change observations three times weekly for 4 weeks to ensure proper technique is being used during dressing changes. Any non-compliance noted will be addressed individually by the DON.

On-going compliance will be monitored through the facility QA process. Any non-compliance will be addressed by the Administrator.

OTHER CONSIDERATIONS WHEN EXECUTING THE POC

Here are some things to consider in this scenario:

- Be sure to observe as many different nurses in this 4 week process because you might not get to pick does the dressing change with the surveyor when they come back for re-survey.

- You’ll create audit tools for each citation. I suggest using a new audit tool for each week of audits. It clearly delineates what was done during each week and takes the guess-work out for the reviewing surveyor. Consider copying and pasting the audit instructions with the frequencies at the top of the audit tool for ease of review for you and your staff. Don’t use resident names as identifiers; use resident initials,  room numbers or medical records numbers instead.

- During QA meetings, there should be reference to the review of these audits and post-survey activities. The QAPI team can discontinue the continued monitoring after those 4 weeks stated in the POC when they feel the concern is no longer an issue.

If the concern is assigned a severity level indicating that a resident was harmed or immediate jeopardy exists (meaning the scope and severity is G-L), all of the following must also be included:

-- A detailed analysis of the facts and circumstances of the finding including identification of its cause. (a Root Cause Analysis)

-- A detailed explanation of how the corrective actions described in the plan relate to the identified cause of the finding.

-- A detailed explanation of the relationship between the ongoing monitoring and improvement process and the identified cause of the finding.

At these upper citation levels, companies may often involve outside legal counsel to assist, particularly if disputing a citation.  

There are times when you will be unable to complete the plan or fix an issue by the last possible date of compliance due to issues outside of your control. In order to prevent monetary penalties or restriction of admissions, the facility will need to request a waiver. The reason why the facility thinks it qualifies for a waiver must be clearly and completely stated. This process could be another blog topic itself. We’ll leave that for another day)

Once submitted, if there are any questions or clarifications needed with the POC, the ODH reviewer will communicate with you through the EIDC system. Each time a correspondence is initiated, those who are listed will get an email alerting them to go into the EIDC to review the communication. The reviewing surveyor may ask for clarifications or more information about your submitted POC. If you aren’t specific about the who, what or when, they’ll let you know what is missing.

If the plan of correction is unacceptable for any reason, the State will notify the facility in writing, like the communication through the EIDC. If the plan of correction is acceptable, the State will notify the facility by phone or e-mail, etc. Facilities should be cautioned that they are ultimately accountable for the own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made in time. Keep track of your dates and if you aren’t hearing back from ODH, call them.

So... I hope this has made the task of writing a POC less daunting. Know that if you have a question, you can reach out and I’ll be glad to help!