Writing Acceptable Plans of Correction

for Assisted Living Facilities (ALF)

Presented by Texas Health and Human Services

Learning and Computer Based Training

Helpful Tips:

• Take responsibility for your own learning.
• Actively participate by investing your time and efforts.
• Turn off your phone and place a sign on your door.
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• Set aside about two hours of uninterrupted time.

Introduction

Target Audience

This presentation was designed for both ALF providers and Health and Human Services Commission (HHSC) staff. The goal of this training is to facilitate an understanding of what constitutes an acceptable plan of correction (PoC) based on identified deficient practices.

Presentation Focus

During the presentation, you will learn to analyze the Statement of Licensing Violations (Form 3724) in order to develop an acceptable PoC.

This presentation will focus on criteria that should be included in the PoC.  The criteria will be covered in depth to help you determine what information is appropriate to include in a PoC.

It is important for providers to understand what the criteria are, how their plans of correction are being evaluated and what makes a PoC acceptable to HHSC.

After each module you will have a review. The review is not scored.  

Objectives

When you have completed this presentation, you will be able to:

• list the three components of a regulatory violation;
• analyze PoCs for acceptability; and
• identify PoC submission requirements.

Writing Acceptable Plans of Correction

Module One

The Provider and the Regulatory Process

Licensure

HHSC licenses ALFs to ensure compliance with state licensing requirements.

Providers must demonstrate not only compliance with requirements, but also the ability to:

• remain in compliance continually; and
• ensure corrective actions are implemented for any deficient practices to prevent reoccurrence.

State licensure requirements for ALFs can be found in the Texas Administrative Code (TAC) located here:

26 TAC, Part 1, Chapter 553.

Initiative and Responsibility

Licensed facilities are expected to take the initiative and responsibility for monitoring their own performance continuously.

Regulatory Services inspects ALF providers to determine if the care they provide meets minimum state requirements in accordance with 26 TAC §553.327.  When a surveyor finds evidence that these requirements are not being met, a violation is written.

Providers should not rely on inspections or investigations to identify compliance problems.

Violations

A licensure violation is a failure on the part of any licensed facility to meet a licensing requirement specified in Title 26, Chapter 553 of the TAC.

Form 3724, Statement of Licensing Violations and Plan of Correction, specifies the violation(s) identified during an inspection or investigation. It supports the citation with evidence about how the facility failed to comply with state requirements.

This form is mailed to the facility within specified time frames.

Form 3724

Form 3724 is important because it:

• documents the official record of the licensing inspection;
• contains information of compliance/noncompliance;
• identifies the impact of the facility's noncompliance on the residents;
• identifies violations of requirements;
• provides the public information about the inspection; and
• provides the facility a tool to write its PoC.

Structure of a Violation

Violations have three components:

• regulatory reference;
• deficient practice statement; and
• relevant findings or evidence.

These components are based on guidance from the Centers for Medicare and Medicaid Services (CMS) Principles of Documentation for writing deficiencies.

HHSC has adopted these guidelines for writing licensing violations.

1st Component-The Regulatory Reference

The regulatory reference includes the inspection tag (e.g., P207). It indicates the references (e.g., TAC, Life Safety Code (LSC)) and describes the requirements the provider must meet.

Example:

P245 TAC §553.253(c)(2),

The facility must ensure that:

Prior to admission, a facility must disclose, to prospective residents and their families, the facility's normal 24-hour staffing pattern and post it monthly in accordance with 26 TAC §553.271.

Regulatory Reference Categories

There are three categories that can describe regulatory references.

Structure Requirements

These are the initial conditions that must be present for licensing and are expected to remain as is (e.g., "Each bedroom measures 100 sq. ft. in single resident rooms" or "Each bedroom has a window").

Process Requirements 

These requirements specify the manner in which a facility must operate and do not allow the facility discretion to vary from what is expected (e.g., the facility must develop individual service plans based on comprehensive assessments).

Outcome Requirements

These requirements specify the results that must be obtained or events that must occur or not occur following an act (e.g., failure to prevent honor an advance directive, failure to ensure residents receive correct medications, or failure to practice safe infection control techniques).

2nd Component-The Deficient Practice Statement

The deficient practice statement indicates the part of the requirement that is not met. It summarizes the issues that demonstrate the facility actions or failure to act that resulted in noncompliance with the requirements.

It also indicates the extent of the deficient practice. This is the number of residents (or items) affected or potentially affected by the deficient practice (e.g., 4 of 6 residents were affected by the deficient practice, or 3 of 7 residents receiving medications, or 15 of 47 sprinkler heads did not meet requirements).

Example:

This requirement was not met as evidenced by:

Based on observation, interview, and record review, the facility failed to have a current physician's order for a medication that was administered for one of four sampled residents (Resident #1).

3rd Component-The Relevant Findings

The relevant findings are the evidence collected by the surveyor to demonstrate the existence of the violation. 

The relevant findings are the result of observations, interviews, and record reviews.

The findings allow the facility to compare what it did or failed to do against what is required. 

The pertinent facts identified in the violation assist the facility in determining the cause of the deficient practice.

Examples of Relevant Findings

Record review of the disclosure statement reflecting staffing patterns provided by the facility indicated that there are to be two attendants present on the night shift (11:00 p.m. – 7:00 a.m.). 

Interview on 03/06/17 at 4:34 p.m. with Shift Supervisor A revealed there was one attendant on duty at night.  Shift Supervisor A further indicated that a security person was available at the residential facility next door.

Interview on 03/06/17 at 5:00 p.m. with the manager confirmed that there was only one attendant on duty at night.

Structure of a Violation-Example

Here is an example of a violation containing all three components. Each component is labeled:

Regulatory Reference

P251 TAC §553.253(c)(2)(F) Employee Staffing-Safe Evacuation 

A facility must have sufficient staff to ensure safe evacuation of the facility in the event of an emergency.

Deficient Practice Statement

The requirement was not met as evidenced by:

Based on record review and interview, the facility failed to have adequate staff to evacuate Resident #1 based on the evacuation capability in the assessment.

Relevant Findings

Record review of the facility's disaster plan, dated 12/14/16, revealed the plan contained information pertaining to the status of the residents' ability to safely evacuate the building. The plan stated each resident was to be assessed on

their evacuation capability.

Record review of Resident #1's assessment indicated he required two-person assistance.

Interview on 03/14/17 at 5:30 p.m. with the only attendant on duty (Attendant C) revealed that she was aware of each resident's ability to evacuate the building in an emergency. She stated she informed the Manager that Attendant D did not report for his shift tonight.

Interview on 03/15/17 at 9:30 a.m. with the Manager revealed that normally two people were present at the facility at all times. The Manager stated, "I could not find anyone to work that shift on 3/14/17."

Determining the Root Cause of a Violation

The PoC process mandates that facilities develop and implement policies and procedures to remedy deficient practices promptly and to ensure those corrections are lasting. 

Facilities must take the initiative and responsibility for monitoring their own performance to sustain compliance.

To develop the PoC, the facility must first analyze the deficient practice to determine what happened and why the problem exists or occurred.

When the facility understands the root cause of the deficient practice, it can develop the solutions needed to correct the problem and sustain compliance. Deficient practice results from either system failures or discrete failures.

ALF Systems

Merriam-Webster's Dictionary defines a system as "a regularly interacting or interdependent group of items forming a unified whole."

In an ALF, systems that promote resident care, comfort, safety and well-being can include, but are not limited to:

• daily management and operation of the facility;

• protection of residents from abuse and neglect;

• delivery of care to residents;

• ensuring freedoms and choices are honored; and

• ensuring staff competency.

Systemic Problems

When the failure involves many or significant items within the system, then it is a system failure. 

The system itself may be absent, or facets of an existing system may not be working. Even minor problems may be indicative of a systemic problem.

For example, if one employee fails to report a single instance of abuse promptly, it could be a system problem if the facility has no policy/procedure for reporting abuse that include the requirement to report abuse immediately and employees have not been trained to report abuse immediately.

A systemic problem requires a PoC that:

• describes what changes in the system will occur to fix the problem; or
• plans for the development and implementation of a new system.

Discrete Problems

These problems may be more difficult to identify. Discrete problems may occur within a system but may only affect a small extent of the entire system.

For example, the problem may reflect an isolated incident, affect one or a few residents or staff, or be present at one or a limited number of times or locations within the facility.

Because even relatively isolated problems could stem from a systemic problem, it is imperative that the facility examine all problems carefully to determine whether there is a system failure before assuming the problem is discrete.

When there are minor or few problems within a system, then the violation may be related to a discrete problem, rather than a systemic problem.

System or Discrete Failure?

Let's look at an example of a situation in which an attendant confessed that he had been abusing residents. 

This could represent a system failure or a discrete failure. 

How could it be a system failure?

Perhaps staff suspected or observed the abuse and failed to report the incident to administration, or the facility failed to screen the applicant before hire.

How could it be a discrete failure?

Perhaps the attendant worked by himself, there were no physical signs of abuse, his victims were not able to communicate, and the facility had no reason to suspect abuse was occurring.

Example of a System Failure

Here is an example of a system failure:

A surveyor observes that Resident #1 coughed 4 times while eating chicken he received during a meal. At another meal, the same resident coughed 2 times while eating bacon.

The evaluation from the occupational therapist dated three weeks prior to this observation recommended a diet texture change to chopped food.

The doctor's orders changed the diet to chopped.

Interviews with attendants indicated they were not aware of a diet change.

The diet card states, "regular texture."

The manager said it's the LVN's "job to change diet cards and train staff."

Example of a Discrete Failure

Here is an example of a discrete failure.

The surveyor observed Attendant B enter the Resident #4's bedroom without knocking. Resident #4 was in the act of changing clothes and was partially disrobed.

Interview with Attendant B revealed that he thought all of the residents, including Resident #4, were in the living room.

There were no other observations of staff entering bedrooms without knocking.

Residents #1, #2 and #3 interviewed indicated that staff always knock before entering the bedrooms.

Differentiating Between Violations

Differentiating between violations that represent a breakdown in a system and those that represent a discrete problem is not always easy, but if the facility does not identify the source of the failure, it will not succeed in correcting it.

Is This a System or Discrete Failure?

Here is an example of a violation. How would you determine whether this is a system failure or a discrete failure?

A facility received a violation for 26 TAC §553.261(e)(10), food must be prepared and served with the least possible manual contact, with suitable utensils, and on surfaces that have been cleaned, rinsed, and sanitized before use to prevent cross-contamination.

The requirement was not met as evidenced by:

The facility failed to prepare and serve food in a manner that was sanitary for 8 of 8 sample residents (Residents #1-8).

A summary of findings included:

Observations revealed that Attendant #1 wiped his nose with alternating hands and coughed into his palms while setting the table, then placed his fingers inside all eight cups as he got them from the cabinet.

Observations of the dinner meal in the facility's dining room revealed that Residents #'s 1-8 drank from the contaminated cups.

Interview on 07/14/17 at 7:05 p.m. with Attendant #1 revealed that he had not been trained on infection control procedures.

Some Things to Consider

Answering these and other questions will help you determine whether the problem is discrete or systemic:

• Are kitchen staff taught about proper food preparation and service sanitation procedures, including the use of gloves?

• If the training exists, did Kitchen Staff A receive the training (she said she did not)? Have all kitchen staff had the training?

• Do other kitchen staff follow food preparation and service procedures?

• Is this an isolated case, or does there seem to be pervasive problems with meeting sanitary food preparation and food service requirements?

Module One Review

Directions: Read and answer each question based on the information in Module One.

Writing Acceptable Plans of Correction

Module Two

Developing a Plan of Correction

Examining the Plan of Correction Criteria

Let's examine the criteria for writing a PoC. 

Those criteria, called PoC criteria, should be used to guide facilities in the development of very specific strategies that delineate exactly what actions will be taken to correct violations.

Once the facility has gathered answers for its questions and analyzed its problems, it can begin to develop a PoC.

There are five criteria that apply to all ALFs.

Criterion 1: What corrective action will be taken for those residents found to have been affected by the deficient practice.

Criterion 2: How other residents with the potential to be affected by the same deficient practice will be identified.

Criterion 3: What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur.

Criterion 4: How the corrective action(s) will be monitored to ensure that deficient practice was corrected and will not recur.

Criterion 5: When the corrective action will be completed.

Criterion 1: Violations with Identifiers

Criterion 1: What corrective action will be taken for those residents found to have been affected by the deficient practice.

Surveyors use codes (called identifiers) to represent residents who were identified as having been affected by the violation (e.g., Resident #1). These identifiers can be found both in the deficient practice statement and the findings.

Violations that impact residents' quality of life or rights are violations of the requirements that must be met for each resident. 

Examples of resident-centered violations include failure to:

• maintain order, safety, and cleanliness;
• prepare and serve meals that meet the daily nutritional and special dietary needs of each resident, in accordance with each resident's service plan; and
• ensure safe evacuation of the facility in the event of an emergency.

Facilities should state what they have done to correct the deficient practice for the residents specifically identified in the violation.

Criterion 1: Violations That Do Not Include Identifiers

Criterion 1 also applies to violations that do not include identifiers. In other words, the violations do not affect specifically identified residents.

Examples of violations without identifiers include failure to:

• develop staff policies;
• complete 16 hours of required training for attendants; and
• designate a facility manager.

Residents may request not to be identified. They may prefer their interview with the surveyor to be confidential. In these cases, identifiers would not be used.

If no residents are identified, then facilities should state what they have done about the identified issue(s).

Address Each Instance of Noncompliance and All Evidence

To meet the PoC Criterion 1, the facility should address what actions it has taken or will take to correct all the evidence listed for each violation.

Criterion 2: Identify Others Who May Be Affected

Criterion 2: How other residents with the potential to be affected by the same deficient practice will be identified.

Facilities should state how all other residents who have been, or could be, affected by the violation have been identified.

To meet PoC Criterion 2, the facility should address:

• how it evaluated or will evaluate other residents who may be affected by the deficient practice; and
• what actions it has taken or will take to protect identified residents from the same threat.

Example

Suppose a facility receives a violation with a deficient practice statement that says: Six out of six residents in the sample were not provided activity or social programs between 06/01/17 and 07/01/17.

The facility's PoC would need to answer the following questions:

• What actions did the facility take to assess other residents for the activities programs they were receiving?
• If the facility determined that activities programs were needed for the other residents, did it implement them?  If so, when?
• How will the facility ensure that activities programs will be designed and implemented for new admissions?

Criterion 3: Systems ALFs Can Implement

Criterion 3: What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur.

Here is an example of a system a facility could put in place to address a violation of §553.265(a)(2), which requires facilities to document in each resident's record whether or not the resident has executed an advance directive. The facility was found to not have all the required documentation in the residents' records.

The facility proposes the following system to correct the violation:

All resident records will be reviewed and corrections will be made for those records lacking the required documentation. The admissions packet will be revised to include a place to document whether or not an advance directive has been executed for any new residents beginning to receive services from the facility. The manager will be responsible for these actions.

Criterion 4: Monitoring of Corrective Actions

Criterion 4: How the corrective action(s) will be monitored to ensure that the deficient practice is being corrected and will not recur; i.e., what program will be put into place to monitor the continued effectiveness of the system changes.

For this criterion, facilities should consider:

• whether they need to develop or modify a monitoring system;
• when the monitoring will occur;
• how often the monitoring will occur; and
• who will conduct the monitoring.

Facilities should monitor their corrective actions after the violation has been corrected to ensure that the violation does not happen again. Monitoring should be ongoing.

Criterion 4: Example of a Monitoring System a Facility May Establish

Here is an example of a monitoring system a facility may establish to ensure that its system corrections are effective:

Let's return to the hypothetical facility mentioned previously that did not have all the required documentation of advance directives in the residents' records.

The facility proposes the following monitoring system to ensure that required advance directive documentation is included in the residents' records:

The manager will review the admissions packet for completeness, ensuring that documentation of the resident's advance directive status is included. The manager or designee(s) will conduct records audits at least quarterly that will include auditing for the required advance directive documentation.

Criterion 5: Date of Completion

Criterion 5: When the corrective action will be completed.

The PoC should identify the date of completion or the expected date of completion for correcting the entire violation.

For this criterion, providers should consider the significance and seriousness of each deficient practice. The amount of time for correction of each violation or deficient practice may vary, depending upon the nature of the violation. Many violations, especially those involving health and safety, can and must be corrected within shorter time frames.

The PoC must be be dated and signed by a facility representative.

Important Points

To ensure that facilities are properly addressing the violation, the PoC must be

• specific;
• realistic; and
• complete. 

The PoC should state exactly how the deficient practice has been or will be corrected. A general statement indicating that compliance has been achieved or will be achieved is not acceptable.

The PoC should identify:

• what corrective action will be taken (i.e., how the corrective action will address the concerns identified in the Form-3724);
• 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 remains corrected;
• the title of the person responsible for implementing the acceptable PoC; and
• what position (e.g., facility manager, the RN, activity director, etc.) will be responsible for monitoring the corrections and the quality assurance mechanisms.

The expected dates of completion for each violation must be within the time frames specified in the letter sent by HHSC.

Achieving and maintaining compliance relies on:

• detecting problems;
• implementing actions to correct the problems; and
• monitoring and evaluating the corrective actions to ensure that the problems won't recur.

All Parts of a PoC Must be Acceptable

An acceptable PoC is required for all ALF licensing violations, including physical plant and facility operation requirements.

When more than one violation is cited, the PoC for each violation must be acceptable in order for the overall PoC to be deemed acceptable. 

All violations cited in the Form 3724 must be individually addressed in the PoC.

Example of an Unacceptable PoC

Let's take a look at an example of a violation a facility might have received and that facility's proposed PoC that would not be considered acceptable. In the interest of brevity, the violation will be summarized.

Directions: Review the findings below and analyze the PoC on the right. Ask yourself why it would be considered unacceptable.

The facility received a violation for §553.253(d)(3) related to training requirements for employees. Direct care staff must complete 6 documented hours of required training annually.

Based on record review and interview, the facility failed to comply with mandatory training requirements by failing to ensure 3 of 4 direct care staff received the required training within the first year of employment.

Specific relevant evidence is cited in the violation to support the deficient practice statement by using identifiers to specify which employees had not completed training. Evidence included each employee's hire date, the dates of training received by each, and the numbers of hours of training each received showing how the requirement was not met.

Exit date 07/13/17.

What Makes This PoC Unacceptable?

The plan does not address each relevant finding (actions to be taken to ensure those employees specifically identified complete the required training).

The plan does not indicate any changes to existing systems, nor does it mention implementation of new systems to ensure that the required training will be completed by new hires in the future; in other words, no systems are mentioned to ensure the violation does not recur.

The facility attempts to dispute the violation in the PoC. There are other procedures in place for facilities to dispute violations. The PoC is still required.

Specific monitoring strategies are not mentioned. The facility's manager does not identify a person or persons responsible for monitoring (or implementing) corrective actions.

Did you identify any other problems with this PoC?

Example of an Acceptable PoC

Now let's take a look at an example of a facility's proposed PoC that would be considered acceptable.

This violation and evidence will be summarized as before, and the facility's proposed PoC is on the right. This time the PoC would be considered acceptable.

Directions: Review the findings below and analyze the reasons the PoC on the right would be considered acceptable. Key words are highlighted in red.

This facility received a violation in the area of providing social activities under §553.309. This requires ALF's to provide a variety of activities, including cognitive, recreational, and activities of daily living (ADL) that meet the needs of the residents.

Based on record review and interview, the facility failed to provide activities to meet the social interest and needs for 4 of 4 residents (#1-4).

A summary of specific relevant evidence:

Residents #1 and #2 were sitting on a couch asleep. Residents #3 and #4 were coloring. Interviews with these residents' family members indicated that coloring was all they did for activities.

Interview with Resident #2's family member indicated that coloring was all that was offered each day.

The activity calendar indicated "arts and crafts" each day. Interviews with staff members revealed that "arts and crafts" consisted of coloring.

Interview with Resident #1 revealed that he didn't like coloring but that was all there was to do all day, every day. He stated he was bored, so he just naps.

Exit date: 07/22/17.

Module Two Review

Directions: Read and answer each question based on the information in Module Two.

Writing Acceptable Plans of Correction

Module Three

PoC Submission Requirements

Submission Time Frames

ALFs must submit an acceptable PoC by the 10th day after receiving the final Form 3724, Statement of Licensing Violations.

(26 TAC §553.331)

Although the actual Form 3724 will not be presented to the facility at the exit conference, surveyors will present sufficient information regarding tentative citations to enable the facility to begin developing a PoC.

The facility is encouraged to submit a PoC as soon as possible and to implement it as soon as possible.

Electronic Submission of Form 3724

There is a procedure for submitting the 3724, Statement of Licensing Violations and Plan of Correction, by e-mail.

If using the Microsoft Outlook version, set up the outgoing e-mail, open the Options menu on the e-mail toolbar and check the box next to the statement: Request a read receipt for this message.   Then select Send.  Print out the message that returns to the sender's inbox and file with the PoC.  

Another option, since there are so many different brands of electronic mail software, would be to send an e-mail message back to the survey office confirming receipt of the 3724. When submitting the completed PoC, request a return e-mail from the survey office as your confirmation that the document was received.

A provider can begin this process by contacting the local survey office by telephone, letter, e-mail or fax to request a copy of Form 3724 be sent to the provider's e-mail address. After sending the completed PoC by e-mail to the survey office, the provider must also submit to the survey office by regular mail or facsimile Page One of the PoC document with the provider's or representative's handwritten signature.

If you need additional information or have specific questions, please contact your regional program manager.  

If Initial PoC is Not Acceptable

After the PoC is submitted, whether or not it was received in the allotted time, HHSC determines whether the plan of correction is acceptable.

If a PoC is not acceptable, HHSC seeks an acceptable PoC by contacting the facility. 

HHSC gives the facility the reasons the PoC was unacceptable and a time frame by which to submit a revised PoC.

HHSC also informs the facility that failure to submit an acceptable PoC within the specified time frame could result in action against the facility's license.

If the Revised PoC is Not Acceptable

If the revised PoC is unacceptable, HHSC Regulatory Services staff will contact the State Office Provider Licensing Enforcement Unit, which will contact the facility concerning possible enforcement actions.

If the facility fails to submit a PoC, HHSC will contact the facility. If HHSC determines that the facility's reasons for failing to submit a PoC are unacceptable, HHSC will follow the same procedure as for an unacceptable PoC.

Informal Dispute Resolution

If the facility chooses to refute violations, it can request an Informal Dispute Resolution (IDR).  A refutation submitted on the 3724 is not an acceptable PoC. The facility is still required to submit an acceptable PoC.

If the facility is contesting violations and is considering whether to delay sending in the PoC until the dispute is resolved, the facility is taking a risk because the enforcement process will continue even without an acceptable PoC.

Other PoC Issues and Reiteration – Part 1

For every violation cited, the facility must provide a PoC. 

It must also provide an anticipated date of completion for each tag on each form.

Each violation may have its own anticipated date of completion, which may be different from the dates provided for each of the other violations listed on the Form 3724.

For example: the anticipated date of completion for §553.253(d)(1)(C) (employee training in universal precautions) may be 07/12/17, and the anticipated date of completion for §553.261(f)(4) (written policy for communicable diseases) may be 07/31/17.

Other PoC Issues and Reiteration – Part 2

When identifying in-service training as part of a PoC, the facility should indicate:

• who will conduct the training;
• what the content of the training will include;
• when and how often the training will be provided; and
• how performance will be monitored to ensure the training was implemented accurately and consistently.

Facilities should submit realistic plans of correction. Facilities should not submit plans of correction that they are not able to implement.

Other PoC Issues and Reiteration – Part 3

The PoC should identify the staff person responsible for any actions or processes implemented.

The PoC should identify how corrections will be monitored and the staff person responsible for the monitoring.

Staff who have been determined to have contributed to a deficient practice should not be solely responsible for implementing the corrective action(s) or for monitoring the corrective processes or actions. 

For example:

The activity director should not be solely responsible for implementing the corrective action and monitoring corrective processes or actions when noncompliance is cited at 26 TAC §553.309.

PoCs should reflect system corrections, not just correction of examples cited on the Form 3724.

Other PoC Issues and Reiteration – Part 4

The PoC should include:

• proactive processes or actions on the part of the facility to identify the system failure;
• concise information on the interventions and actions the facility will develop/revise and implement to address the identified issues;
• ongoing systems to evaluate the effectiveness or progress of implemented systems;
• the title of a person who will be responsible for the system/actions; and
• the title of a person who will be responsible for evaluating the effectiveness of the implemented systems.

Other PoC Issues and Reiteration – Part 5

It is possible for facilities to receive multiple survey documents related to different purposes of visits. The documents may include the same tags or different tags. Each document received requires a PoC.

Example:

On a complaint investigation, §553.261(e)(6) related to food spoilage was cited. Three months later, at the annual licensing inspection, §553.261(e)(6), was noted to be uncorrected and was re-cited. 

One Form 3724 is generated for the follow-up to the complaint investigation; then another one is generated for the annual licensing inspection. 

PoCs are required for both of the 3724s; however, the facility can use the same PoC for both 3724s.

On-site Revisits

HHSC may conduct an on-site revisit to follow up with the facility concerning its plan of correction.

The purpose of the revisit is to confirm that the facility has regained compliance with licensing requirements and has the ability to remain in compliance. The facility should remember this in selecting its PoC completion date.

The facility can typically show evidence of monitoring by summarizing what measures it has taken to ensure sustained compliance.

TIP-You may want to keep a binder or folder that contains documentation or evidence of correction. That will help you track your own progress towards correcting the deficiency or violation, while providing organized evidence of correction that you can show to a surveyor during a revisit.

The PoC as a Management Tool

The provider plays a singular role in achieving and maintaining compliance. The provider must know the requirements and provide services that meet those requirements. Therefore, it is important that all staff learn the licensing requirements within their areas of responsibility. Staff knowledge and individual responsibility are key factors in achieving and maintaining compliance.

Facilities must take the initiative and responsibility for monitoring their own performance so that they are always in compliance with licensing requirements.

The PoC is a valuable management tool because it requires facilities to:

• achieve and maintain compliance;
• ensure that the underlying cause of cited violations does not recur;
• make changes that will result in improved care delivery for residents; and
• improve provider operations.

More Than Correcting Violations

Developing a successful PoC involves more than just reading a violation and developing a plan to correct it. 

It requires the provider to analyze the statement of licensing violations and determine the underlying problem that generated the violation.

When systems are in place for each type of service and when the facility consistently monitors its practices and makes adjustments as necessary, compliance will be achieved and maintained.

When a system or part of the system isn't working, it is the facility's responsibility to recognize and correct the problem, preferably before the surveyor finds a deficient practice.

When a violation is identified and cited, the provider is required to correct the identified violation and ensure that it does not recur.

Module Three Review

Directions: Read and answer each question based on the information in Module Three.

Conclusion

The importance of developing an acceptable plan of correction cannot be over-emphasized.

The implementation an acceptable plan of correction goes a long way toward ensuring continued quality care for the residents receiving its services.