All licensed health care companies, whether facilities are home health or hospice providers, must complete regular surveys to verify compliance with local, state, and federal regulatory organizations. While the goal is always to receive no deficiencies, sometimes companies fall short of regulatory standards.
If your organization is found to be deficient in any categories, hospice plans of correction are required. These aren’t difficult to complete or submit, but there are a few common mistakes you might make along the way. Don’t worry; we’re here to help.
What is a Plan of Correction?
After a survey by the State Agency, your organization may receive a statement of deficiencies. The statement is prepared on Form CMS-2567, which lists the deficiencies on the left, and then provides a second area on the right side of the form for your response, or the plan of correction.
Certain language is expected, with very particular vocabulary, and you’ll have a strict deadline for submission. You may also want to provide exhibits with your POC (should we define what this is) to support any of the actions you set forth in your plan. Then, you must follow through with your plan within a set time frame or run the risk of failing a re-inspection, which could result in fines. The state will supply a deadline for compliance, but you can also set an earlier deadline on your own. Once the state’s deadline passes, you could be surveyed again at any time.
Elements of Deficiency Citation
It’s important to understand the elements of both the deficiency citation and the plan of correction because you’ll need to cross-reference the elements when preparing your POC. On the statement of deficiency, you’ll see a reference to regulations, the practice that has been found deficient, and then any other relevant findings. Some of these findings may be noted with an asterisk, which indicates that correction is not needed if other safeguards are in place to protect the patients.
The regulatory reference will have a survey data tag number, the Code of Federal Regulation or Life Safety Code reference, and then information about that particular reference as it applies to the deficiency. The practice statement includes specific actions, lack of actions, or errors that led to a deficient finding, as well as identifiers for the people or situations that led to the finding.
Elements of a POC
When preparing hospice plans of correction, you must keep five elements in mind. First, the corrective action, the affected individuals, and how it will be achieved. Second, identify other individuals or situations that may be affected by the deficiency and how your corrective action will change the potential results.
Next, identify changes that must be made within your system to ensure the deficiencies will not occur again. Fourth, you’ll identify how your business will monitor the corrections to show continuous action with improved performance.
Finally, identify when these corrective actions will be accomplished so that your business will again be fully complaint.
Why is a POC necessary?
Keep in mind this form is an official record of the survey, which makes official any findings of compliance and/or noncompliance. This record will then be available to the public upon request, which could affect a potential client’s decision to choose your facility.
If this sounds like a very important undertaking, you are correct. There are several missteps and mistakes you might make along the way. But, as we promised in the beginning, we’re here for you every step of the way. A qualified and experienced consultant can help you address your hospice plans of correction as needed. We can even help with mock surveys to ensure that you’re ready for the agency to visit again once your POC has been submitted and corrective actions have been taken.