Developing Written Plans of Correction

Purpose

The purpose of CMS2567.COM is to provide assistance in preparing a plan of correction when federal and state deficiencies are issued. Providers and suppliers wishing to participate in the Medicare/Medicaid/Clinical Laboratory Improvement Amendment (CLIA) programs are required to submit an acceptable plan of correction (POC) for achieving compliance in response to deficiencies issued by the state survey agency and the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA).

CMS2567.COM believes that compliance with these guidelines will avoid a provider's or suppliers submission of an unacceptable plan of correction which may unnecessarily delay compliance with cited deficiencies, increase time to rewrite and review the plan of correction and jeopardize the provider's or supplier's certification status

Certification Actions

The Department or CMS issues a Statement of Deficiencies (CMS-2567), to the provider or supplier if the survey or investigation identifies violations of the federal or state regulations. The CMS-2567 identifies the federal or state regulation in violation and describes the findings of noncompliance. The provider or supplier is required to submit a written response to these deficiencies. This response is known as the Plan of Correction (POC). The POC must identify the steps that have been or will be taken to attain compliance with the regulation and must identify the time that correction has been or will be achieved by the provider or supplier. The Department or CMS must accept the POC in order to allow the provider or supplier to continue in the federal and state certification programs. Approval of the POC is based on the following:

The POC must be specific, realistic and complete. The POC must state exactly how the deficient practice has been or will be completed. A general statement indicating that compliance has been achieved or will be achieved is not acceptable. The POC must identify the nature of the corrective action, and how the corrective action will not only address the concerns identified in the CMS-2567, but will also address other situations where there is a potential for noncompliance with the cited regulation. The POC must also identify what systematic changes will be made to ensure that the deficient practice will not recur and how the facility will monitor its corrective action to ensure that the deficient practice is corrected, i.e. what quality assurance program will be put into place. The POC must identify the position of the staff person(s) who will be responsible to monitor correction and the quality assurance mechanisms, such as the Administrator, Director of Nursing or Laboratory Director. The CMS-2567 and the subsequent POC is accessible to the public and a clear and specific response by the provider or supplier identifying the steps taken to achieve-compliance and to prevent a recurrence of noncompliance is important.

The POC must also identify the date of completion or the expected date of completion. The Department or CMS is required to determine that the specified time periods are reasonable. The amount of time for correction will vary depending upon the nature of the deficiency. The maximum amount of time is 60 days from the exit date of the survey unless special circumstances warrant. However, the Department or CMS will not routinely accept 60 day time frames for compliance when a deficiency can reasonably be corrected well before that date. Many deficiencies, especially those involving the provision of direct care, can and must be corrected within shorter time frames. If state licensing orders accompanied the CMS-2567, the times for correction identified in the state orders should be used.

A deficiency may require several corrective actions in order to achieve compliance, with each action having different dates of completion. These dates should be clearly identified in the POC.

The completed CMS-2567 must be returned to the Department within 10 calendar days of receipt. If the POC is not properly completed or if additional information is needed, the provider will be contacted for clarifications and modifications. An acceptable plan of correction must be submitted and correction of all deficiencies made.

A guideline of specific procedural steps to use when completing the written plan of correction follows. If you have any questions on completing a plan of correction, please contact your assigned Licensing and Certification office or OHFC Supervisor, or call the Health Policy, Information and Compliance Monitoring Division, Licensing and Certification Section at (651) 215-8701.

Guidelines

The I.D. Prefix Tag of the deficiency to which you are responding will be printed in the middle column. Start the written plan of correction next to the Tag Number and, if necessary, complete on a separate sheet of paper.

Indicate how the specifics of the deficiency will be or has been corrected. Indicate the system(s) that will be or was put into place to assure the deficiency will remain corrected.

Required Components

  • How the corrective action(s) will be accomplished for those residents found to be affected by the deficient practice:
  • How the facility will identify other residents having the potential to be affected by the same deficient practice:
  • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur:
  • How the facility plans to monitor its performance to make sure that solutions are sustained. This plan will be implemented, and the corrective action evaluated for its effectiveness. This plan of correction is integrated into the quality assurance system:

Identify the position of the staff person(s) who will be responsible to monitor the above systems(s), such as Director of Nursing Services, or Laboratory Director.

Indicate the one expected date of completion for correcting the total deficiency in the last column and place the one date across from the computer identification prefix tag number. Since some deficiencies may require several intermediate corrective actions to achieve compliance, indicate the different dates of completion for these within the body of the response.

Although federal regulations allow a maximum of 60 days from date of exit for correction of deficiencies, that is to be considered an outside limit and is not appropriate for all deficiencies. Many deficiencies should be corrected in a shorter time frame.

Deficiencies related to direct patient care, can and should be corrected immediately and noted as such in the POC.

Return the Written Plan of Correction to the Unit Supervisor or Director, OHFC within 10 calendar days from the date it was received.

Sign and date the CMS-2567.




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