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:

  • follow up for three months following a recommendation that an individual needed glasses for 1 of 3 sample individuals;
  • ensure that individuals' money management programs were carried out at individuals' work sites for 6 of 6 individuals; and
  • monitor training and services at the day habilitation center for an individual for six months following the individual's admission into the program for 1 of 2 individuals attending the center.


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:

  • There was not a system in place to monitor the QIDP's work.
  • The QIDP was out of the office for an extended period of time, and no one was put in charge to cover the QIDP's duties.
  • There was a shortage of DCS which resulted in a loss of constant active treatment. 


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