New Guidelines for Writing Plans of Correction.
The State Operations Manual (SOM) Transmittal #13, released in December 1999, describes newly updated requirements for submitting a plan of correction. An acceptable plan of correction must:
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
2. Address how the facility will identify other residents having the potential to be affected by the deficient practice;
3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. At the revisit, the quality assurance plan is reviewed to determine the earliest date of compliance. If there is no evidence of quality assurance being implemented, the earliest correction date will be the date of the revisit; and finally,
5. Include dates when corrective action will be completed. 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, email, etc. Facilities should be cautioned that they are ultimately responsible 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 in timely fashion. The plan of correction will serve as the facility's "allegation of compliance."
Notice that element #4 has been expanded to include a specific statement: "The plan of correction is integrated into the quality assurance system." This means that it is imperative for the facility's administrator to immediately convene the quality assurance committee, following a survey, to develop, implement and monitor the plan of correction. The quality assurance committee should carefully select the most effective corrective actions, assign specific corrective actions to departments and individuals, establish realistic timetables for their implementation, vigorously oversee that they are executed in accordance with the plan and, most importantly, evaluate their effectiveness.
Hint: Assess the facility's quality assurance committee composition and processes now to be ready for the next survey.
According to the new guidelines, "At the revisit, the quality assurance plan is reviewed to determine the earliest date of compliance." This means that surveyors will ask the facility's administrator to produce a written quality assurance plan to prove that the proposed corrective actions actually occurred in accordance with the alleged date of compliance. Providers have usually been advised not to share copies of quality assurance materials with surveyors, but providing this written document is now the designated means of proving correction.
Hint: Begin now, even before your next survey, to prepare a written format for presenting the required information.
The guidelines continue, "If there is no evidence of quality assurance being implemented, the earliest correction date will be the date of the revisit." If the quality assurance committee cannot prove (in writing) that deficiencies were corrected by the dates specified in the plan of correction, then the surveyors will declare the facility in compliance effective only with the exit date of the revisit, not retroactive to the alleged date of compliance. Therefore, if a facility has received serious enforcement remedies, such as a civil monetary penalty or denial of payment for new admissions, the remedy could continue until the exit date of the revisit, even if the revisit occurs days, weeks or even months after the alleged date of compliance.
Hint: Make certain that the quality assurance committee verifies correction of deficiencies on the quality assurance plan consistent with the alleged date of compliance.
Element #5 states: "Facilities should be cautioned that they are ultimately responsible 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 in timely fashion." This means that if your state's survey agency does not promptly inform you whether your plan of correction is deemed to be acceptable, you are still responsible for carrying out corrective actions anyway. The facility's administrator should plan to contact the state survey agency to find out the status of the plan of correction within five (5) days following submission. When the state notifies facilities of their acceptance or nonacceptance, the good news may be delivered via telephone, facsimile or email, and the bad news must be delivered in writing (somehow).
Hint: The facility's administrator should handle the contact with the state survey agency and take notes from the telephone call or retain a copy of a fax notification or e-mail correspondence.
Finally, element #5 also specifies that "The plan of correction will serve as the facility's 'allegation of compliance.'" This means it is no longer necessary to prepare a separate letter stating that the facility is formally alleging compliance through transmission of the plan-of-correction.
I hope that this will clarify the new processes--but I hope even more that you have a deficiency-free survey and never have to follow these plan-of- correction guidelines!
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|Author:||Klitch, Beth A.|
|Article Type:||Brief Article|
|Date:||Apr 1, 2000|
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