Writing Acceptable Plans of Correction
for Home and Community Support Services Agencies

Writing Acceptable Plans of Correction

for Home and Community Support Services Agencies

Computer based training.

Presented by Texas Health and Human Services

Welcome

You have launched a computer-based training that covers the requirements for writing an acceptable plan of correction for home and community support services agencies (HCSSAs) in Texas.

 

This computer-based training is presented by Texas Health and Human Services.

 

To navigate through this course, use the buttons at the bottom left of the screen.

 

Click "next page" to proceed to the next page and click "previous page" to go back to the previous page.

 

You may also access content directly by using the "Contents" drop-down menu or the page numbers across the top of the page.

In this training, be sure to click the text that appears in blue underlined text for important additional information.

 

Image of compass.

 

Main Menu

This presentation is divided into four sections concerning the process surrounding the development of acceptable plans of correction.

 

Table of contents.

Section 1 – Introduction

Section 2 – The Provider and the Regulatory Process

Section 3 – Developing an Acceptable Plan of Correction

Section 4 – Submission Requirements

 

 

 

Writing Acceptable Plans of Correction for Home and Community Support Services Agencies (HCSSAs)

Section 1 - Introduction

Introduction

Target Audience

 

This presentation was designed for both Home and Community Support Services Agencies (HCSSAs) providers and Texas Health and Human Services (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.

 

Target image.

Presentation Focus

Image of focus.

During the presentation, you will learn to analyze the Statement of Deficiencies or Statement of Licensing Violations in order to develop an acceptable PoC.

 

This presentation will focus on criteria that must 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.

 

 

 

Objectives

 

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

  • list the criteria required for writing an acceptable plan of correction;
  • utilize the criteria to address violations and deficiencies;
  • identify PoC submission requirements; and
  • identify the consequences for failure to submit an acceptable plan of correction.

 

Image of checklist.

 

Writing Acceptable Plans of Correction for Home and Community Support Services Agencies (HCSSAs)

Section 2 - The Provider and the Regulatory Process

conference meeting

Licensure & Certification

 

rules and regulations

HHSC licenses HCSSAs to ensure compliance with state licensing requirements. State licensure is based on the Texas Health and Safety Code (HSC) and the rules promulgated in Title 26 of the Texas Administrative Code (TAC); all HCSSAs must be licensed.

 

Optional federal certification for home health and hospice agencies is based on the Code of Federal Regulations (CFR) and requirements promulgated through the Centers for Medicare & Medicaid Services (CMS).

 

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

  • their ability to remain in compliance continually; and
  • that the corrective actions and follow-up methods implemented ensure the deficient practice does not recur.

State Licensure Requirements: Title 26 TAC, Part 1, Chapter 558

Federal Home Health Certification Requirements: Title 42 CFR, Part 484

Federal Hospice Certification Requirements: Title 42 CFR, Part 418

 

Initiative and Responsibility

 

HCSSAs are expected to take the initiative and responsibility for monitoring their own performance continuously so that they are always in compliance.

 

HHSC surveyors conduct surveys of HCSSAs to determine if the care they provide meets minimum state requirements and minimum federal requirements if applicable (26 TAC §558.525). When a surveyor finds evidence that applicable requirements are not being met, a violation or deficiency is written.

 

Providers should not rely on surveys or investigations to identify compliance problems. The diligent implementation of required internal processes, such as the analysis of satisfaction surveys and the Quality Assurance and Performance Improvement process, will help the agency identify and address compliance problems proactively.

Violations and Deficiencies

 

Violation image.

Violation

  • Failure on the part of the agency to meet a licensing standard based on Chapter 142 of the HSC and set forth in 26 TAC Chapter 558.
  • Form 3724, Statement of Licensing Violations and Plan of Correction, specifies the violation(s) identified during a survey or investigation and supports the citation with evidence about how the agency failed to comply with state requirements.
  • Form 3724 documents failure to comply with state requirements (Z-tags). It is mailed to the agency within specified time frames.

Deficiency

  • Failure on the part of the certified agency to meet a federal standard specified in 42 CFR Part 484 (for home health agencies) or Part 418 (for hospices).
  • Form CMS-2567, Statement of Deficiencies, specifies the deficient practice identified during a survey or investigation and supports the citation with evidence about how the agency failed to comply with federal requirements.
  • Form CMS-2567 documents failure to comply with federal requirements (G-tags or L-tags). It is mailed to the agency within specified time frames.

 

 

Form 3724 and CMS-2567

 

 

Form 3724 and CMS-2567 are important because:

  • they are the official records of the survey;
  • they are the official documents of compliance and/or noncompliance;
  • they identify the impact of the agency's noncompliance on its clients/patients;
  • they identify violations of regulations;
  • they are available to the public upon request; and
  • the agency uses them to write its plan of correction.

 

Forms Icon.

 

Structure of Violations and Deficiencies

 

Number three.

Both violations and deficiencies have three components:

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

These components are based on guidance from CMS Principles of Documentation for writing deficiencies.

HHSC has also adopted these guidelines for writing licensing violations.

 

Component 1: The Regulatory Reference

 

The regulatory reference includes the licensure/certification tag (e.g., Z119 or G106). It indicates the reference (e.g., TAC, CFR, or Life Safety Code for inpatient hospices) and describes the requirements that are to be met by the provider.

 

Example: Z427 §558.290(b) - After hours care. An agency must adopt and enforce a written policy to ensure that clients are educated in how to access care from the agency or another health care provider after regular business hours.

 

Man looking up a reference.

Regulatory Reference Categories

 

There are three categories that a regulatory reference can fall into.

Structure Requirements

These are the initial conditions that must be present for licensure or certification and are expected to remain as is.

Example: Z115, "A license holder or the license holder's designee must designate in writing an alternate administrator who meets the qualifications and conditions of an administrator to act in the absence of the administrator."

Process Requirements

These requirements specify the manner in which an agency must operate and do not allow the agency discretion to vary from what is expected.

Example: Z476, "(Each client record must include the following elements as applicable to the scope of services provided by the agency…) clinical and progress notes. Such notes must be written the day service is rendered and incorporated into the client record within 14 working days."

Outcome Requirements

These requirements specify the results that must be obtained or events that must occur or not occur following an act.

Example: Z478, "(Each client record must include the following elements as applicable to the scope of services provided by the agency…) medication administration record (if medication is administered by agency staff). Notation must also be made in the medication administration record or in the clinical notes of medications not given and the reason. Any adverse reaction must be reported to a supervisor and documented in the client record."

Component 2: The Deficient Practice Statement

 

Important image

The deficient practice statement indicates the part of the requirement that is not met. It summarizes the issues that demonstrate the agency's actions or failures to act that resulted in noncompliance with the requirement.

 

It also indicates the extent of the deficient practice. This is the number of clients or patients affected or potentially affected by the deficient practice. For example, a deficient practice statement may state that 4 out of 6 clients, or 3 out of 7 patients receiving intravenous care, were affected by the deficient practice.

 

Example:

This requirement was not met as evidenced by:

Based on a review of the agency's drug policy, the agency's admission packet, and interviews, the agency failed to provide a copy of the agency drug testing policy to 2 of 2 clients (Clients #1 and #2).

 

Component 3: The Relevant Findings

 

Relevant findings are the "evidence" collected by the surveyor to demonstrate the existence of the violation or deficiency.

 

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

 

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

 

The listing of the pertinent facts identified in the violation or deficiency assists the agency in determining the cause of the deficient practice.

 

Example of relevant findings for tag Z194, Verification of Employability and Use of Unlicensed Persons:

 

The findings include:

  • Review of the agency's personnel records for Employees #50, #51, and #52 revealed no Criminal History checks, Nurse Aide Registry checks, or Employee Misconduct Registry checks were documented.
  • An interview was conducted on [date] at [time] with the administrator, who confirmed the agency had not conducted Criminal History checks, Nurse Aide Registry checks, or Employee Misconduct Registry checks for Employees #50, #51, and #52.

 

Relevant

 

Use of Identifiers

 

identify

When the CMS-2567 or Form 3724 refers to agency staff or clients/patients, it uses identifiers (e.g., Client #1 or LVN A) rather than names to protect confidentiality.

 

Some deficiencies and violations do not include identifiers because they do not affect specifically identified clients/patients, rather they pertain to certain operational requirements that have the potential to affect all patients/clients in the agency. Some examples of deficiencies without identifiers include failure to develop policies that prohibit abuse and neglect orfailure to prohibit the employment of those whose employment is precluded by pre-employment screening.

 

Structure of a Violation or Deficiency Example

 

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

Regulatory Reference

Z222 558.249(c), Self-Reported Incidents of Abuse, Neglect, and Exploitation

If an agency has cause to believe that a client served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, meaning within 24 hours, to:

(1) the Department of Family and Protective Services (DFPS) at 1-800-252-5400, or through the DFPS secure website at www.txabusehotline.org; and

(2) HHSC Complaint and Incident Intake (CII) at 1-800-458-9858.

Deficient Practice Statement

This requirement was not met as evidenced by:

Based on record review and interview, the agency failed to report an incident of exploitation immediately to HHSC at 1-800-458-9858 and the Department of Family and Protective Services (DFPS) at 1-800-252-5400 for Client #1.

Relevant Findings

The findings included:

  • Review of the complaint intake form for incident #12345 identified that the agency reported an incident of exploitation for Client #1 to HHS on 6/8/19. Review of the provider investigation report dated 6/8/19 indicated the agency received the allegation on 4/20/19 but did not report the incident to HHS until 6/8/19, approximately six weeks later. Review of the DFPS confirmation report indicated that the agency reported the incident to DFPS on 6/8/19. The agency failed to report the incident immediately to HHSC and TDFPS as required.
  • On 7/18/19 at 2:05 PM, the Administrator verified that the allegation was received on 4/20/19 and that the incident was not reported to HHSC or DFPS until 6/8/19.

 

 

Determining the Root Cause of a Violation or Deficiency

 

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

 

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

 

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

 

When the agency 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.

Root Cause Analysis

HCSSA Systems

 

Dictionary

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

 

In a HCSSA, systems that promote patient/client care, comfort, safety, and well-being can include but are not limited to:

  • daily management and operation of the agency;
  • protection of patients/clients from abuse and neglect;
  • delivery of health care to patients/clients;
  • ensuring care is coordinated among staff, contracted staff, outside professionals, and other HCSSAs providing care; and
  • ensuring staff competency.

Part of the administrator's responsibilities include organizing and directing the agency's ongoing functions, which involves a responsibility for oversight of the agency's systems. Likewise, the Quality Assurance and Performance Improvement Committee is responsible for the annual evaluation of the agency's total operations, which entails a review of agency systems. An effectively functioning administrator and committee are essential to ensuring the effective functioning of agency systems.

 

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 services were not initiated within the timeframes established by the agency's policy for one out of seven clients, it could be a systemic problem if the coordination of information exchange within the agency was so disorganized that staff responsible for scheduling visits did not know when a client was admitted.

 

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

 

Identify problem

 

Discrete Problems

 

Problem

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 or affect one or fewer patients/clients or staff.

 

Because even relatively isolated problems could stem from a systemic problem, it is imperative that the agency 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 or deficiency maybe 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 a home health aide confessed that she had been abusing a client.

 

This could represent a system failure or a discrete failure.

 

How could it be a system failure?

Perhaps other staff or family members suspected or observed the abuse and failed to report the incident to the agency's administration, or if the agency failed to screen the applicant before hire.

 

How could it be a discrete failure?

Perhaps the home health aide worked by herself, there were no physical signs of abuse, her victim was not able to communicate, and the agency had no reason to suspect abuse was ocurring.

Problem type

 

Example of a System Failure

 

Here is an example of a system failure:

 

The surveyor determined that the agency failed to enforce its client care policy regarding assessments.

  • The agency's policy states, "Assessment(s) by additional discipline(s) will be completed as soon as possible, but no later than 72 hours of request for that discipline's services."
  • Client #2 had an order for occupational therapy evaluation. Occupational therapy did not attempt to complete an evaluation visit until 20 days after the referral date.
  • Client #7 had a physician's order for a medical social worker evaluation. The medical social worker evaluation was not completed until 16 days after the referral date.
  • Client #17 had a physician's order for a medical social worker evaluation. The medical social worker evaluation was not completed until thirteen days after the referral date.
  • Client #27's plan of care included orders for physical therapy services. The initial physical therapy evaluation visit was completed four days after the referral date.
  • Client #36's plan of care included orders for physical therapy services. The initial physical therapy evaluation visit was completed five days after the referral date.
  • In an interview, the Director of Nursing (DON) confirmed that each of these evaluation visits was completed outside the timeframes established by policy on the dates indicated in the clinical records. The DON stated, "It's really hard getting those therapists out to see our clients. They have a lot of clients all over town."

 

 

Example of a Discrete Failure

 

Here is an example of a discrete failure:

  • The agency's policy titled "Staff and Volunteer Performance Evaluations" stated that performance evaluations would be conducted after the first 90 days and annually. The employee's evaluation form would be placed in the employee's personnel file.
  • Review of the Alternate Supervising Nurse's personnel file included a 90-day performance evaluation that was dated 100 days after hire.
  • No other staff or volunteer evaluations were delinquent. Upon interview, the Administrator stated that the Alternate Supervising Nurse was in a car accident at around 75 days after hire and did not return to work until 90 days after hire. The Administrator was on a two-week cruise to the Bahamas at the time of the Alternate Supervising Nurse's return to work and completed the evaluation within two days of her return from vacation.

 

 

Differentiating Between System Failure and Discrete Failure

 

Differentiate

Differentiating between violations that represent a breakdown in a system and those that represent a discrete problem is not always easy, but if the agency 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?

 

The agency received a violation for Tag Z410, Coordination of Services, related to the requirement to document coordination of care between all service providers involved in the care of a client, including physicians.

 

The requirement was not met as evidence by:

Based on interview and record review, the agency failed to document that coordination of care occurred between the physician and agency staff in that the agency nurse did not notify the physician of a client's change in condition for 1 of 3 sampled records reviewed (#1).

 

The relevant evidence follows on the next page.

Fail stamp.

Is This a System or Discrete Failure? Continued

 

The example continues.

 

A summary of the findings included:

  • Client #1 had been hospitalized for 10 days following a heart attack.
  • Client #1's plan of care stated, "Skilled nurse (SN) check vital signs (every) visit and report to MD (Medical Doctor) if above or below the following parameters: SB/P (systolic blood pressure) greater than 180 and less than 90, DB/P (diastolic blood pressure) greater than 90 and less than 60."
  • At one visit, the client's blood pressure was 158/92, which was out of the given reporting parameters. The clinical record did not contain any evidence that the abnormal blood pressure was reported as ordered to the physician.
  • Three weeks later, the client's blood pressure was 149/95. The clinical note did not contain any evidence that the physician was notified.
  • In an interview, the LVN stated that "I didn't realize I was supposed to report diastolic pressures above 90. The client told me her doctor only worries about it if it's over 100.

 

 

 

Things to Consider

 

Things to consider.

Here are some things to consider in determining whether the problem is discrete or systemic:

  • What is the agency's process for communicating reporting parameters to clinical staff?
  • How do clinical staff learn of reporting parameters?
  • Do they have access to reporting parameters at the time of the visit?
  • If there is a pattern of clinical staff not being aware of reporting parameters, how could the agency modify its systems to ensure that the right staff have access to the right information at the time of service delivery?

 

 

Writing Acceptable Plans of Correction for Home and Community Support Services Agencies (HCSSAs)

Section 3 - Developing a Plan of Correction

Hands writing

Key Points to Remember

 

Here are some key points to remember regarding the plan of correction:

  • The PoC is required.
  • The agency must develop a PoC for each cited deficiency and violation on each survey report received.
  • Preparing a PoC is not construed as an admission of wrong-doing.
  • Not preparing a PoC opens the agency up to possible enforcement action.
  • The agency must prepare a PoC even if it disagrees with the findings or is planning to request an informal review of deficiencies.
  • The PoC must be typed or written legibly in blue or black ink.
  • The PoC for a given violation or deficiency must be typed or written in the right column of the statement of violations or deficiencies next to the appropriate tag number and violation/deficiency.

 

Remember post-it

 

Four Elements of a Plan of Correction

 

Number four

Let's examine the criteria for writing a plan of correction.

 

Plans of correction must address four core elements:

  • who;
  • what;
  • how; and
  • when.

Those elements require the development of very specific strategies that delineate exactly what actions will be taken to correct violations and deficiencies. Once the agency has gathered the answers for its questions and analyzed its problems, it can begin to develop a PoC.

Element 1: Who?

 

The agency must provide the title of the person responsible for correcting the violation or deficiency.

 

The agency must also include the title of the person responsible for implementing the plan of correction.

 

The agency must not use proper names.

 

Example: The supervising nurse will in-service all staff on the agency's infection control and universal precautions policies.

Who

Element 2: What?

 

The second required element is the agency's plan for correcting the specific deficiency or violation cited. The plan must address the process leading to the deficiency or violation and include a monitoring procedure for ensuring ongoing compliance.

 

The plan should not address the specific examples cited in the deficiency or violation.

 

Example: Given a deficient practice regarding staff failure to follow universal precautions, an example of a part of the agency's plan of correction that addresses this element would be:

  • Staff are required to wear disposable gloves while providing treatments, wound care, incontinent care, and bathing. After providing care to each patient, a staff person is required to thoroughly wash his or her hands. The supervising nurse will randomly observe 20% of staff as they perform these patient care activities to determine whether agency infection control policies have been followed.

 

What

 

Element 3: How?

 

The PoC must also include the procedures for implementing the plan of correction for the specific deficiency or violation cited. A successfully implemented PoC puts into place measures or systemic changes that will ensure that the deficient practice will not recur.

 

The agency should consider whether it needs to develop or modify a system.

 

Example: The supervising nurse will record her findings [regarding staff following universal precautions] and report to the administrator weekly. The administrator will compare the reports for patterns and trends and identify staff who need further training. Staff who fail to comply after receiving additional training will receive disciplinary action. After one month, the administrator will evaluate all reports to see if the measures taken resulted in improved compliance. The plan will continue with monitoring on a monthly basis for three months, then quarterly.

 

How

Element 4: When? (part 1)

 

When will the problem be corrected? This is the completion date. Each deficiency or violation must have a completion date. The earliest acceptable date is the day after the survey was completed.

 

In determining the correction date, the agency should consider the significance and seriousness of each deficient practice. The amount of time for correction should vary, depending on the nature of the deficiency or violation; however, the amount of time is dependent, by rule, on the Severity Level of the violation. The time frames given in the TAC are the maximum times for completion. Violations often can, and should, be corrected before the deadline is reached.

  • A Severity Level B violation that results in serious harm to or death of a client or constitutes a serious threat to the health or safety of a client must be addressed upon receipt of the official written notice of the violations and corrected within two days.
  • A Severity Level B violation that substantially limits the agency's capacity to provide care must be corrected within seven days after receipt of the official written notice of the violations.
  • A Severity Level A violation that has or had minor or no health or safety significance must be corrected within 20 days after receipt of the official written notice of the violations.
  • A violation that is not designated as Severity Level A or Severity Level B must be corrected within 60 days after the date the violation was cited.

See 26 TAC §558.527(g)(2) for more information.

When

 

Element 4: When? (part 2)

 

For federal deficiencies, certification is allowed only if the agency "has submitted an acceptable PoC for achieving compliance within a reasonable period of time."

 

After a PoC is submitted, HHS makes the determination of the appropriateness of the PoC.

 

This "reasonable period of time" (to achieve compliance) is generally no longer than 60 calendar days. Of course, the correction date for a specific deficiency may be less or greater than 60 calendar days after the survey depending on the circumstances of the deficiency.

 

HHS will not routinely accept dates for correction for 60 calendar days when the deficiency can reasonably be corrected well before 60 calendar days. On the other hand, a provider may reasonably require more time than 60 calendar days to correct some deficiencies (e.g., those requiring construction or those that are clearly beyond the control of the provider). - State Operations Manual, 2728B

 

An agency must submit an acceptable PoC for each violation or deficiency no later than 10 days after its receipt of the official written notification of the survey findings (i.e., CMS-2567 and/or Form 3724) to the appropriate HHSC regional HCSSA program manager. - State Operations Manual, 2728B and 26 TAC §558.527(g)(3)

 

Calendar

Ongoing Monitoring

 

Monitoring

Monitoring should continue, even after the deficient practice is corrected.

 

If an agency states that its corrective actions will be monitored only through its plan of correction date, it is not ensuring that the deficient practice will not recur.

 

Agencies should monitor their corrective actions after the deficiency or violation has been corrected to ensure that the deficient practice does not happen again.

 

Other Requirements

 

In addition to the four core requirements, the plan of correction must also comply with the following:

 

  • The plan of correction must also be dated and signed by the administrator or other authorized official.

 

  • The plan of correction must not include proper names, allude to another provider, or malign an individual according to the State Operations Manual 2728B.

 

  • It is acceptable to use staff designated titles, e.g., the agency LVNs, the supervising nurse, the medical director, the administrator, the supervisor, etc.

Requirements

 

Summary: Important Points

 

Make your plan of correction:

  • specific;
  • realistic; and
  • complete.

Identify how the corrective action will address the concerns noted on the statement of violations or deficiencies. A general statement indicating that compliance has been achieved or will be achieved is not acceptable. The plan of correction must state exactly how the deficient practice has been or will be corrected.

 

Identify the systemic changes that will be made to ensure that the problem does not recur.

 

Specify how you will monitor the corrective action.

Summary

Example: Unacceptable Plan of Correction (part 1)

 

Unacceptable

Let's take a look at an example of a violation an agency might have received and that agency's proposed plan of correction that would not be considered acceptable.

 

In the interest of brevity, the violation will be summarized then there will be an example of a plan of correction.

 

Try to ascertain some of the reasons the example of the plan would be considered unacceptable.

 

Example:

The agency received a violation for Z194, 26 TAC §558.247, concerning employability of unlicensed persons. The agency must request a criminal history check on new, unlicensed applicants for employment. The survey exit date was 7/13/19.

Based on review of employee files and staff interview, the agency failed to comply with Health and Safety Code, Chapter 250, in that criminal history checks of employees who provide direct client care were not conducted within 72 hours of employment in 2 of 3 employee files reviewed (employee files #6 and 8).

 

Example continues on next page.

Example: Unacceptable Plan of Correction (part 2)

 

Unacceptable

 

The example continues.

 

Findings include:

  • Review of Employee #6's personnel file indicated a hire date of 06/07/19. A "Computerized Criminal Record Search" form dated 06/15/19 indicated a search was conducted more than 72 hours after hire date.
  • Review of Employee #8's personnel file indicated a hire date of 06/05/19. A "Computerized Criminal Record Search" form dated 07/06/19 indicated a search was conducted more than 72 hours after hire date.
  • Employees #6 and #8 have direct contact with the agency's clients.
  • In an interview on 07/13/19 at 4:00 p.m., the administrator confirmed that the criminal history checks were performed late.

 

Example continues on next page.

 

Example: Unacceptable Plan of Correction (part 3)

 

Unacceptable

The example continues.

 

The agency's PoC was:

 

The administrator will review all employee files to ensure that there are no further discrepancies. As new staff are hired, the administrator will conduct required criminal history checks within 72 hours. The QA/PI Committee will review employee files annually to verify this has been done. This procedure will be implemented by 7/31/19.

 

What makes this PoC unacceptable?

  • While the plan does state who is responsible for implementing the plan, it does not address ongoing monitoring.
  • The QA/PI Committee's annual review does not constitute ongoing monitoring.
  • No plan is set into place to ensure that the required checks are performed, only to catch when it wasn't done after the fact.
  • Z194 constitutes a Severity Level B violation, which means it must be corrected within either two or seven days after the receipt of the official written notice of the violation (depending on whether it results in serious harm to or death of a client or constitutes a serious threat to the health or safety of a client).

Did you identify any other problems with this PoC?

Example: Acceptable Plan of Correction (part 1)

 

Now, let's take a look at an example of an agency's proposed plan of correction that would be considered acceptable.

 

This violation and evidence will be summarized as before and the agency's proposed plan of correction follows. This time the plan of correction would be considered acceptable.

 

Try to ascertain some of the reasons the plan of correction would be considered acceptable.

 

Example: The agency received a violation for Z448, 26 TAC §558.297, concerning physician's orders. The agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when receiving physician orders. The exit date was August 6, 2019.

 

Based on review of clinical records and policies and on interviews, the agency failed to enforce its written policy regarding the procedures agency staff must follow when receiving physician orders for 1 of 7 active clients (Client # 6).

 

Example continues on next page.

Example: Acceptable Plan of Correction (part 2)

 

Acceptable.

The example continues.

 

Findings include:

  • The agency's policy reads: "Admission of Patients—If the initial referral does not contain an order to make an evaluation visit, the registered nurse (RN) will call the physician and obtain a telephone order for the evaluation visit and any other orders the physician believes necessary to establish the plan of care. The RN will write the telephone order(s). The orders(s) will be immediately sent to the physician for his countersignature. The orders(s) will be placed in the clinical record."
  • Review of the clinical record of Client #6 revealed a start of care date of 06/06/19. The clinical record did not contain a plan of care, nor did the clinical record contain physician orders authorizing the agency to provide skilled nursing services. The agency provided skilled nursing visits on the following dates without physician's orders: 06/06/19, 06/08, 06/13, 06/15, 06/20, 06/22, 06/27, 06/29, and 07/03/19.
  • An interview was conducted on 08/06/19 with the Alternate Administrator (RN) at 10:00 AM. The Alternate Administrator stated, "I received the physician's orders for home health services, but I did not write them down. The plan of care was not in the chart because our office person was not coming in."

 

Example continues on next page.

Example: Acceptable Plan of Correction (part 3)

 

Acceptable.

The example continues.

 

The agency's PoC was:

 

Staff are required to adhere to the agency's policy regarding admission of patients and physician orders. The Alternate Administrator will review the policy with all agency RNs by 8/8/19. The agency's initial evaluation form will be modified to include a reminder to the assessing RN to verify that a plan of care and physician's orders have been received. The QA Nurse will conduct a chart audit of all client records and identify any other clients for whom an order has not been received and any identified problems will be corrected within 5 days. Each month, the QA Nurse will review a sampling of 50% of new admissions to verify that physician orders have been received and will report any problems to the Alternate Administrator for correction. The effectiveness of these measures will be evaluated by the QA/PI Committee at each meeting and modified as necessary. Correction date: 8/10/19.

 

What makes this PoC acceptable?

 

This plan is acceptable because it addresses the system, rather than the specific instance, and it includes an ongoing monitoring program to ensure compliance. All responsible staff are identified and the correction date is acceptable.

 

Did you identify anything else that makes this example an acceptable PoC?

Links to Examples

 

Below are links to supplementary documents related to this training.

  • Click here to open a document containing examples of unacceptable and acceptable PoCs intended to further illustrate the PoC criteria.
  • Click here to open a document showing an example of a violation that you can use to complete an optional exercise to practice developing your own PoC using all of the criteria stated in this presentation.

You can print these documents now, then review them (or complete the optional exercise) later, at your leisure after exiting this course.

Examples

Writing Acceptable Plans of Correction for Home and Community Support Services Agencies (HCSSAs)

Section 4 - Submitting a Plan of Correction

 Business meeting

Submission Time Frames

 

HCSSAs must submit an acceptable plan of correction within 10 calendar days of receipt of the CMS-2567 or Form 3724.

  • Failing to do so may result in an administrative penalty, per 26 TAC §558.527(g)(3).
  • Failure to submit a PoC for federal deficiencies within 10 days of receipt of the CMS-2567 could result in HHSC recommending termination of the provider agreement.

Although the actual CMS-2567 or Form 3724 will not be presented to the agency at the exit conference, surveyors will present sufficient information regarding tentative citations to enable the agency to begin developing a PoC.

 

The agency is encouraged to submit a plan of correction as soon as possible and to implement as soon as possible.

Consequences

 

There are serious consequences for not following submission requirements.

 

A Medicare-certified agency's failure to submit a plan of correction or failure to submit a plan of correction within specified time frames could result in termination of the provider agreement! More on this can be found in 42 CFR §488.28(a) and §488.456(b)(i).

 

HHSC also has the option of recommending enforcement actions for licensed HCSSAs.

Consequences

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 agency. HHSC informs the agency:

  • the reasons the PoC was unacceptable;
  • the time frame by which to submit a revised PoC; and
  • a statement that failure to submit an acceptable PoC within the specified time frame will result in immediate termination of the agency's provider agreement (for certified HCSSAs) or action against the agency's license (for licensed-only HCSSAs).

 

The agency must submit a revised plan of correction no later than 30 days after its receipt of HHSC written notice of an unacceptable PoC (26 TAC §558.527(g)(4)).

 

Remember that the state and federal enforcement processes are independent of the PoC process—in other words, enforcement actions, such as terminations, will not be delayed, even if the agency's PoC is late or needs revision to become acceptable.

Errors

If the Revised PoC is Not Acceptable

 

If the agency's revised plan of correction is still not acceptable, HHSC can pursue enforcement actions.

  • For certified HCSSAs, HHSC sends the agency a letter proposing termination of certification. CMS will then send the agency a letter terminating certification.
  • For licensed HCSSAs, HHSC may recommend enforcement action.

It is in the agency's interest to ensure that its plans of correction meet the criteria outlined in this course, in the document "How to Write an Acceptable Plan of Correction" (which is given to the agency at exit), and in S&CC Letter 07-13, Unacceptable Plan of Correction (PoC) Procedures.

Errors

Informal Dispute Resolution

Dispute resolution

After HHSC completes a survey, HHSC sends the official, written notification of the survey findings to the HCSSA, including a statement of deficiencies and/or violations, a statement regarding the HCSSA's opportunity for an Informal Dispute Resolution (IDR), and instructions for requesting an IDR.

 

A HCSSA must submit a plan of correction in response to an official written notification of survey findings that declares a deficiency or violation, even if the agency disagrees with the survey findings.

 

If a HCSSA disagrees with the survey findings, the agency may request an IDR and submit additional written information to refute a deficiency or violation to demonstrate compliance in an informal setting. A HCSSA may contact the regional HCSSA program manager prior to submitting a request for an IDR, if needed, to discuss the official written statement of deficiencies or violations received.

 

See Provider Letter 16-42 for further information.

Other Plan of Correction Issues (part 1)

 

For every violation or deficiency cited, a PoC must be provided. The PoC must include all of the required criteria.

 

For all violations and deficiencies, an anticipated date of completion must be provided for each tag on each form.

 

Each violation or deficiency may have its own anticipated date of completion, which may be different from each of the other violations or deficiencies listed on the Form 3724 or CMS-2567.

 

For example, the anticipated date of completion for Z213 (relating to volunteers) may be 10/31/17, and the anticipated date of completion for Z129 (relating to the administrator's responsibility for ensuring the accuracy of public materials) may be 10/05/19.

Issues

Other Plan of Correction Issues (part 2)

When identifying in-service training as part of a plan of correction, the agency 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 elements addressed in the training were implemented accurately and consistently.

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

 

Issues

 

Other Plan of Correction Issues (part 3)

The plan of correction must identify the staff person responsible for any actions or processes implemented.

 

The plan of correction must 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 or actions, nor for monitoring the corrective processes or actions.

 

For example, the administrator should not be solely responsible for implementing the corrective action nor for monitoring corrective processes or actions when noncompliance is cited at the administrator tags.

 

PoCs must reflect system corrections, not just correction of examples cited on Form 3724 or CMS-2567.

Issues

 

Other Plan of Correction Issues (part 4)

The PoC should involve:

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

 

Issues

 

 

Other Plan of Correction Issues (part 5)

 

It is possible for agencies to receive multiple documents due to the multiple purposes of visits. The documents may include the same tags or different tags. Each document received requires a plan of correction.

  • An example may be that during a complaint investigation, Z203 was cited. Three months later, at the annual licensure survey, Z203 was noted to be uncorrected and was re-cited.
  • One Form 3724 will be generated for the follow-up to the complaint investigation, and another one will be generated for the licensure inspection. A plan of correction will be required for both of the Form 3724s; however, the agency can use the same plan of correction for both Form 3724s.

It is acceptable to reference the plan of correction for different deficiencies or violations if the corrective action is identical. For example: The plan of correction for Z149 may state "Refer to Z147."

Issues

 

Other Plan of Correction Issues (part 6)

Agencies need to ensure that they received all the pages of the CMS-2567 or Form 3724 (including blank last pages).

 

In some instances, the federal data system prints a blank last page due to the set up for the last printed line at the bottom of the previous page. The page format is not adjustable by the surveyor because it is set within the system. The document must be returned the same way it was received.

 

All pages, including blank pages, must be returned to the Regulatory Services office specified in the PoC letter that accompanied the CMS-2567 or Form 3724.

Issues

 

On-site Revisits

 

On-site

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

 

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

 

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

 

Under specific conditions (e.g., lack of a policy unrelated to patient care), state violations cited in the PoC may be such that a mail or telephone follow-up visit will suffice for licensed-only citations.

 

However, the HCSSA regional program manager has the option to convert it to an on-site visit if insufficient information is received by the agency to answer all questions about the PoC.

 

See S&CC 06-02 for additional information.

The PoC as a Management Tool (part 1)

The agency plays a singular role in achieving and maintaining compliance.

 

The agency must know the requirements based on the applicable state and federal regulations in order to provide services that meet those requirements.

 

Therefore, it is important that all staff learn all applicable requirements within their areas of responsibility. Staff knowledge and individual responsibility are key factors in achieving and maintaining compliance.

 

Agencies must take the initiative and responsibility for monitoring their own performance so that they are always in compliance.

 

hands holding tools

 

 

The PoC as a Management Tool (part 2)

 

The PoC is a valuable management tool because it requires agencies 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 patients/clients; and
  • improve agency operations.

 

hands holding tools

 

 

More than Correcting a Violation/Deficiency

Success

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

 

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

 

An agency achieves and maintains compliance when systems are in place for each type of service and when the agency consistently monitors its practices and makes adjustments as necessary.

 

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

 

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

 

Conclusion

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

 

An agency that submits and follows an acceptable plan of correction goes a long way toward ensuring continued quality care for the patients/clients receiving its services.

Conclusion

Thank you!

 

 

This brings us to the conclusion of this training.

 

Thank you for participating.

 

Thank you