Correcting the Specific Deficiency: Deficiencies that Include More Than One Relevant Finding

Occasionally, the deficient practice statement will include more than one example of relevant findings, or evidence.

Relevant findings are the facts relevant to the deficient practice that answers the questions who, what, where, when, and how. Therefore, there can be more than one relevant finding for a deficiency or violation.

The example below pertains to W159 which states, "Each client's active treatment program must be integrated, coordinated, and monitored by a QIDP."

The specific deficiency is that the QIDP did not integrate, coordinate, and monitor each individual's active treatment program. The relevant findings are listed below.

The QIDP failed to:

The facility will need to address both the W159 deficiency and the processes that led to the deficiency that was cited.

Examples of possible processes that led to the deficiency could include:

Note: The examples above are abbreviated and not as detailed as what should be on a CMS 2567 form or HHS Form 3724.