Writing Acceptable Plans of Correction (PoCs) for Intermediate Care Facilities for Individuals with Intellectual Disabilities or Related Conditions (ICFs/IID)

Target Audience

This computer based training (CBT) was designed for both ICF/IID providers and Regulatory Services staff to facilitate an understanding of what constitutes an acceptable plan of correction (PoC) based on identified deficient practices.

This CBT was developed to improve effectiveness and consistency in writing PoCs.

The purpose of this training is to promote quality of care and quality of life for individuals in ICFs/IID.

Click the Checking in . . .  link to answer questions throughout the course.

Section 1: Introduction

Presentation Focus

In this CBT you will learn to analyze the Statement of Licensing Violations, the Statement of Deficiencies, and the State Standards for Participation Violations in order to develop an acceptable PoC.

This CBT focuses on elements that must be included in the PoC to help you determine what information is required.

It is important for providers to understand how PoCs are evaluated and what makes a PoC acceptable to Regulatory Services.

Learning Objectives

In this training, you will:

• compare a system failure with a discrete failure;
• identify the elements required in an acceptable PoC; and
• evaluate the appropriateness of PoC elements in a violation/deficiency.

Section 2: The Provider and the Regulatory Process

Licensure and Certification

All ICFs/IID are federally certified. Many are both certified and also licensed by the state. Non-licensed facilities, such as state supported living centers (SSLCs) and community centers, are certified.

The state of Texas surveys ICFs/IID to ensure the facility is in compliance with the rules and regulations.

State licensure is based on the Texas Administrative Code (TAC). The ICF/IID licensing standards are located in 26 TAC Chapter 551.

Federal certification is based on the U. S. Code of Federal Regulations (CFR) and requirements established through the Centers for Medicare & Medicaid Services (CMS).

The State Operations Manual (SOM) Appendix J contains information on certification requiremets for ICF/IID programs and the survey process.

Initiative and Responsibility

Participation in Medicare/Medicaid mandates that facilities take the initiative and responsibility for monitoring their own performance continuously to ensure they are always in substantial compliance.

Surveyors from Regulatory Services conduct surveys of ICFs/IID to determine if the care they provide meets minimum federal and state standards. When a surveyor finds that evidence exists indicating standards are not being met, he/she will write a violation/deficiency.

Facilities should not rely on surveys or investigations to identify compliance problems.

State Violations

Facilities licensed by the state of Texas must comply with 40 TAC Chapter 90 which is based on Chapter 252 of the Texas Health and Safety Code (THSC).

Facilities that are not licensed by the state must meet specific federal requirements and three subchapters of 26 TAC Chapter 551:

• Subchapter C - Standards for Licensure;
• Subchapter D - General Requirements for Facility Construction; and
• Subchapter F - Inspections, Surveys, and Visits

A licensing violation is a failure on the part of a state-licensed facility to meet these requirements.

State Violations (cont'd)

HHS Form 3724 is a licensure violation form for documenting failure to comply with state requirement M tags and and federal Life Safety Code (LSC) K tags.

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

The State Standards for Participation (S tags) are rules pertaining to compliance with contractual requirements. The HHS Form 3724 is used to document the violations.

Federal Deficiencies

All ICFs/IID must meet specific federal requirements.

A deficiency is a failure on the part of the facility to meet a federal standard specified in SOM Appendix J.

The form CMS 2567 Statement of Deficiencies, specifies the deficient practice identified during a survey or investigation. It supports the citation with evidence about how the facility failed to comply with federal requirements (W tags).

If a surveyor cites a tag, Regulatory Services will mail the HHS Form 3724 and CMS 2567 to the facility within 10 business days from the date of exit.

CMS 2567 and Form 3724

 The CMS 2567 and Form 3724 are important because they:

• are the official records of the survey;
• are the official documents of compliance/noncompliance; and
• identify the impact of the facility's noncompliance on the individuals.

QUICK REVIEW

Directions: Click the Checking in . . . link below.

 Checking in . . .    

Structure of a Deficiency/Violation

Deficiencies/violations that surveyors write have three components. They are:

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

Keep in mind that both violations and deficiencies are called citations. [CMS, Principles of Documentation (PoD)]

1st Component: The Regulatory Reference

The regulatory reference:

• lists the survey tag;
  • W tag, K tag, M tag, or S tag
• indicates the references; and
  • CFR, LSC, or TAC
• describes the requirements that the facility must meet.

Example of a Regulatory Reference

W251 - §483.440(d)(3), Program Implementation

Except for those facets of the individual program plan (IPP) that must be implemented only by licensed personnel, each individual's IPP must be implemented by all staff who work with the individual, including professional, paraprofessional, and nonprofessional staff. 

1st Component: The Regulatory Reference (cont'd)

A regulatory reference can fall into three categories.

Structure Requirements

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

W198 - Clients who are admitted by the facility must be in need of and receiving active treatment services.

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.

W206 (excerpt) - Each client must have an individual program plan developed by an interdisciplinary team.

Outcome Requirements

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

W247 - (The individual program plan must also) Include opportunities for client choice and self-management.

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's actions, or failures to act, that resulted in noncompliance with the requirements.

It also includes the extent of the deficient practice. This is the number of individuals, or items, affected or potentially affected by the deficient practice.

For example:

• 4 out of 6 individuals were affected by the deficient practice;
• 3 out of 7 individuals with behavior intervention plans; or
• 15 out of 47 sprinkler heads

Example of a Deficient Practice Statement

Based on observations, interviews, and record reviews, the facility failed to develop training programs for individuals who demonstrated they needed assistance in dressing themselves for 4 of 6 individuals (Individuals #1, 2, 3 and 4).

3rd Component: The Relevant Findings

Relevant findings are the evidence collected by the survey team to demonstrate the existence of the deficient practice. 

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 listing of the pertinent facts identified in the deficiency allows the facility to discover what caused the deficient practice.

3rd Component: The Relevant Findings (cont'd)

Example of Relevant Findings

Record review of Individual #2's individual program plan (IPP), dated 7/2/16, revealed that her habilitation center training objective was as follows, "Individual #2 will receive services in the areas of eating, range of motion, social, mobility, and grooming." Further review revealed that the objective did not state the criteria that Individual #2 must accomplish in order to achieve the objective.

Record review of Individual #2's program data folder for 7/16 and 8/16 revealed that there were no data sheets for this program.

Record review of Individual #3's IPP, dated 3/15/16, revealed that her habilitation center training objective was as follows, "Individual #3 will improve her range of motion, self-help skills, skin integrity, and positioning by mastering two of three objectives by March 2016." Further review revealed that the objective did not state the criteria that Individual #3 must accomplish in order to achieve the objective.

The listing of the pertinent facts identified in the deficiency allows the facility to discover what caused the deficient practice.

Interview with the Qualified Intellectual Disability Professional (QIDP) on 8/11/16 at 1:30 p.m. revealed that the day habilitation objectives for Individuals #2 and #3 were designed to maintain the skills that they already have and not teach them new skills or enhance their existing skills.

QUICK REVIEW

Directions: Click the Checking in . . . link below.

 Checking in . . .    

Construction of a Violation/Deficiency

Example of a Deficiency/Violation with Three Components

Regulatory Reference

W455 §483.470(l)(1), There must be an active program for the prevention, control, and investigation of infection and communicable disease.

This REQUIREMENT was not met as evidenced by:

Deficient Practice Statement

Based on observation and interviews, the facility failed to prevent cross-contamination during meals for 6 of 6 individuals (Individuals # 1 - 6).

Relevant Findings/Evidence

Observations on 7/14/16 from 5:40 p.m. to 6:02 p.m. in the facility's dining room revealed that Individual #1 wiped his nose with alternating hands and coughed into his palms while setting the table. Individual #1 touched the eating surfaces of the forks and spoons as he placed all six individuals' silverware on the table. The house manager and direct care staff (DCS) A were in the room, approximately 10 feet away from Individual #1, and were not observed to intervene.

Observations on 7/14/16 from 6:02 p.m. to 6:26 p.m. of the dinner meal in the facility's dining room revealed that Individuals # 1 - 6 ate their dinner with the contaminated silverware.

Interview on 7/14/16 at 7:05 p.m. with the house manager revealed that she did not observe Individual #1 contaminate the tableware because, in her words, "I was training (DCS A)."

Interview on 7/14/16 at 7:11 p.m. with DCS A revealed that he did not notice Individual #1 contaminate the tableware because, in his words, "I can't watch (Individual #1) and be trained at the same time."

Determining the Root Cause of a Violation/Deficiency

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 why it 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.

ICF/IID Systems

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

In an ICF/IID, systems that promote individual care, comfort, safety, and well-being can include, but are not limited to:

• overseeing daily management and operation of the facility;
• providing active treatment;
• protecting individuals from abuse and neglect;
• delivering health care to individuals;
• ensuring freedoms and choices of individuals are honored; and
• ensuring staff competency.

Systemic Problem

A system failure is a failure involving significant or multiple items within the system.

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

A systemic problem requires a PoC that describes the:

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

QUICK REVIEW

Directions: Click the Checking in . . . link below.

 Checking in . . .   

Discrete Problems

Discrete problems may be more difficult to identify. Even though they may occur within a system, they could affect only a small part of the entire system.

For example, the problem may:

• reflect an isolated incident;
• affect a small number of individuals or staff;
• be present at one time or a limited number of times; or
• be present in various locations.

When there are minor or few problems within a system, then the violation/deficiency may be related to a discrete problem, rather than 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. Even relatively isolated problems could stem from a systemic problem.

Systemic or Discrete Failure

At first glance, a complex situation could appear to be either a systemic or discrete failure. In such a case, the facility must examine it critically to determine the ultimate basis of the failure.

Once the facility fully assess the cause of the failure and determines its type, it must take steps to correct the failure and the circumstance of its existence.

QUICK REVIEW

Directions: Click the Checking in . . . link below.

Differentiating Between Deficiencies

Differentiating between deficiencies or violations that represent a breakdown in a system and those that represent a discrete problem is not always easy.

However, a facility probably will not succeed in correcting the failure if it does not identify the source of the failure.

Example

W473 §483.480(b)(2)(ii), Food must be served - at appropriate temperature.

Based on observations and interviews, the surveyor learned that the facility failed to ensure hot food was served at an appropriate temperature for 6 of 6 individuals (Individuals # 1 - 6).

A summary of the findings includes:

• At 5:02 p.m. Individual #s 1-6 and DCS A went to a fast food restaurant and purchased boxes of chicken for dinner. They returned at 5:27 p.m.
• Upon their return, DCS B removed 2 pizzas from the oven.
• Dinner was served at 5:51 p.m. (24 minutes after the pizzas were taken from the oven and the chicken had arrived).
• Temperature readings of the food at the time it was served were 78 degrees for the pizza and 72 degrees for the chicken.
• Individual #s 1, 3, and 4 ate chicken. Individual #s 2, 5, and 6 ate pizza.
• Individual #3 said, "Yuck, this chicken is cold!"
• DCS B stated she was trained that hot food should be served right away.
• The QIDP stated she trains staff on an annual basis to serve hot food immediately after it is prepared

How would you determine whether this is a system failure or a discrete failure?

Differentiating Between Types of Deficiencies

You might investigate the reason for the 24-minute delay from when the food was ready to eat to the time dinner was served.

You might also investigate whether the food was actually cold.

Things to Consider

Is there a pattern of meals being delayed at this time of day?

possible discrete problem

Are meals delayed at other times during the day?

possible systemic problem

Was this an isolated situation caused by unusual circumstances?

possible discrete problem

If there is a pattern of delayed meals, you may ask how could present systems be modified or new systems be implemented to correct the problem.

Section 3: Developing an Acceptable Plan of Corrections

Examining the Plan of Correction Elements

There are four PoC elements that an ICF/IID must address when developing its PoC.

Those elements require the facility to develop specific strategies that delineate exactly what actions they will take to correct deficiencies.

Once the facility has investigated the issue and generated a corrective strategy, it can begin to develop the PoC.

Plan of Correction Elements

An acceptable PoC must contain the following elements:

1. The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited;
2. The procedure for implementing the acceptable PoC for the specific deficiency cited;
3. The monitoring procedure to ensure that the PoC is effective and that the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; and
4. The title of the person responsible for implementing the acceptable PoC.

Note: Survey and Certification (S&C) 17-34, released June 16, 2017, included new guidance on what elements an acceptable PoC must contain. The title of the letter is New Guidance for the Formatting of the Plans of Correction, and you can access it by clicking S&C 17-34.

1^st Element: Correcting the Specific Deficiency

The first element of an acceptable PoC is, "The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited."

This first element of an acceptable PoC needs to cover what the facility is going to do in order to correct the deficiency.

A facility's PoC should address what processes or events led up to the deficiency. This will ensure all aspects of why the deficiency occurred are explored.

Correcting the Specific Deficiency

The PoC needs to address how the facility is going to correct the specific deficiency.

In the situation of a facility failing to ensure quarterly evacuation drills, the PoC should address the following questions:

• What actions did the facility take to monitor that evacuation drills were being done?
• Who was responsible for conducting the evacuation drills?
• Do both staff and individuals participate during drills?

Processes that Led to the Deficiency

The PoC should also address the processes that led up to the deficiency.

The following are examples of processes that could have led to the deficiency, failure to ensure quarterly evacuation drills:

• New personnel were not fully trained in their duties.
• There was no back-up plan in place for when staff, who are responsible for conducting evacuation drills, were unavailable.
• There was no system to monitor when evacuation drills were completed

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.

Address Each Instance of Noncompliance and All Evidence

To meet the first element of an acceptable PoC, the facility should address what action(s) it has taken or will take to correct all the evidence listed for each deficiency/violation.

All instances of noncompliance and all evidence must be addressed in the PoC.

Analyzing the Specific Deficiency

What actions should a facility take given a deficient practice statement that says the following?

Based on interviews and record reviews, 2 of 4 sample individuals were started on psychoactive medication regimens for inappropriate behaviors before written informed consent was obtained.

W263 was cited.

Six of 6 individuals at this facility are on psychoactive medication regimens and could be affected and have the potential to receive medications without consent.

The facility's PoC should address the following questions:

• Are any other consents lacking?
• How will the facility ensure that any lacking informed consents will be obtained for individuals on psychotropic medication regimens?
• What process led to individuals receiving psychotropic medication without written consent and how will it be corrected?

Informed consent is required for all individuals taking psychotropic medication. The facility would need to document when the individuals' consents were obtained.

Note: This is not a comprehensive list of all the possible items the facility would need to address.

QUICK REVIEW

Directions: Click the Checking in . . . link below.

 Checking in . . .   

2^nd Element: Procedure for Implementing the Plan of Correction

The second element of an acceptable PoC is, "The procedure for implementing the acceptable PoC for the specific deficiency cited."

The facility first identifies the specific deficiency and what led up to the deficiency being cited.

Then, the facility must explain how their PoC will be implemented for the specific deficiency.

To meet the requirements of this second element, facilities must:

• describe the process to implement the PoC;
• break down the steps needed; and
• ensure the PoC will correct the deficient practice.

Using the last example, say the facility's PoC included implementing a new system for obtaining written consent for psychotropic medications.

The PoC would need to detail how this new system would work, and how the facility would coordinate the use of this new system.

A System for Addressing a Deficiency

The following is a example of a system to address an abuse, neglect, and exploitation (ANE) deficiency:

• The unit management team will review all facility incident reports on a daily basis. 
• The incident management team will review incidents that involved injuries (including those of an unknown cause and non-reportable injuries) or allegations of abuse or neglect on the next business day. 
• QIDPs are expected to convene interdisciplinary team (IDT) meetings to address all injuries and allegations of abuse or neglect within 24 hours of the date of discovery.
• QIDPs must submit a copy of the IDT meeting minutes to the unit director and quality assurance director. 
• QIDPs must ensure that the IDT considers the following:
  • all the facts gathered to date;
  • history of similar incidents/allegations; and
  • programs designed to address the situation

3^rd Element: Monitoring Procedure

The third element of an acceptable PoC is, "The monitoring procedure to ensure that the PoC is effective and that the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements."

For this element, the facility must devise a way to monitor the PoC.

The facility must ensure the PoC is working effectively and that the deficiency remains corrected. Monitoring of corrections involves documenting answers to the following questions:

• Does the facility need to develop or modify a monitoring system?
• When will the monitoring occur?
• How often will the monitoring occur?
• Who will conduct the monitoring?

The facility should specify at what minimum frequency the monitoring will occur.

Facilities must write the title of the person conducting the monitoring, not the proper name.

An Effective Monitoring Procedure

Below is an example of a facility's monitoring procedure for a deficiency for inadequately monitoring the training services at the day habilitation center.

The administrator will verify through weekly QIDP notes that the QIDP is monitoring training and services at the day habilitation center.

The administrator will maintain a Day Habilitation Center Log that includes specific information, such as:

• date of observation;
• individual's name;
• IDT objectives and steps;
• progress/lack of progress/regression notes; and
• investigation follow up.

Note: This is an abbreviated example.

Having a monitoring procedure will ensure that the system corrections are effective.

An Effective Monitoring Procedure (cont'd)

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

• The administrator will verify through daily review of facility incident reports that the QIDP investigates all non-serious injuries of unknown origin. 
• The administrator will maintain a Non-Reportable Injuries of Unknown Origin Log that includes the date of the incident, the name of the individual, the injuries sustained, the suspected cause, IDT intervention, when the individual's family was notified, the date that the completed investigation was submitted, and if any issues needed follow up. 

Ongoing Monitoring

Remember monitoring should continue after the deficient practice is corrected.

If a facility states that its corrective actions will be monitored only through its PoC date, it is not ensuring that the deficient practice will not reoccur.

There should be no completion date for monitoring. It should be ongoing.

4^th Element: Responsible Person

The fourth element of an acceptable PoC is, "The title of the person responsible for implementing the acceptable PoC."

The PoC must identify the title of the person responsible for any processes implemented.

It must also identify how corrections will be monitored and who is responsible for the monitoring. 

Specific Plans of Correction

To ensure that facilities are properly addressing the deficient practice, the PoC must be specific, realistic, and complete.  The PoC must state exactly how the deficient practice has been or will be corrected.

The PoC must identify the nature of the corrective action.

A general statement indicating that compliance has been achieved or will be achieved is not acceptable.

The more specific the PoC, the easier it is to plan and track its implementation.

QUICK REVIEW

Directions: Click the Checking in . . . link below.

 Checking in . . .   

Sections of an Acceptable Plan of Correction

An acceptable PoC is required for all deficiencies/violations to be in compliance.

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

It is not necessary for a facility to re-write the corrective action for different deficiencies/violations if the corrective action is identical. For example, the plan of correction for W255 may state, "Refer to W159." This is acceptable if the facility plans on using the same corrective actions for a deficiency written at W255 and W159.

All deficiencies cited on the CMS 2567 and all violations cited on Form 3724 must be individually addressed in the PoC.

Use of Names or Titles

The PoC must not:

• include proper names;
• allude to another provider; or
• malign an individual.

It is acceptable to use staff designated titles. For example, the:

• facility LVN;
• QIDP;
• program director;
• facility administrator;
• facility's contracted psychologist, etc. 

The PoC must also be dated and signed by the administrator or other authorized official. His or her title must be included (SOM 2728B).

Staff Contributing to a Deficient Practice

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

For example, the following people should not be solely responsible for implementing or monitoring corrections:

• The QIDP should not be solely responsible for implementing the corrective action or for monitoring corrective processes or actions when noncompliance is cited at the QIDP tag (W159).
• The nurse should not be solely responsible for implementing the corrective action or for monitoring corrective processes or actions when noncompliance is cited at the nursing tags (W331 or W338).
• The administrator should not be solely responsible for implementing the corrective action and for monitoring corrective processes when noncompliance is cited at the governing body tags (W102 or W104).

In-service Training

There are times when training will need to be part of a facility's PoC. That might be refresher training or a new training topic.

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 elements addressed in the training are implemented accurately and consistently.

Realistic Plans of Correction

A facility's PoC needs to be realistic.

Remember, the PoC that is submitted and accepted is what the facility will be expected to implement.

A facility must ensure, and be certain, the plan it creates can be implemented, monitored, and followed.

Unacceptable Plan of Correction

Take a look at an example of a deficiency a facility received and the unacceptable PoC they proposed.

 As you read, try to ascertain some of the reasons the PoC would be considered unacceptable.

Note: The deficiency and evidence are summarized on the subsequent slides. The proposed PoC follows the slides.

Deficiency Summary

The facility received a deficiency for W120 §483.410(d)(3), Services provided under agreements with outside sources.

The facility must assure that outside services meet the needs of each client.

This requirement was not met as evidenced by --

Based on observations, interviews, and record review, the facility failed to ensure that the day habilitation center met an individual's need for purposeful activities for 1 of 1 individual reviewed for using a day habilitation center (Individual #1).  

Deficiency Summary (cont'd)

The surveyor noted the following specific relevant evidence:

• Individual #1 observed quickly thumbing through pages in a magazine or coloring on paper for over an hour at a day habitation center.
• Staff were not observed to encourage Individual #1 to participate in a non-leisure activity.
• Individual #1 has expressed interest in group activities and never refused to participate.
• Individual #1 has a training objective that he is supposed to work on at the day habilitation center. He did not receive the specified training during the observation.

Exit date 06/15/16.  

Proposed Plan of Correction: Unacceptable Response

The facility proposes the following PoC.

Note: The third column will be filled out for you on the next slide. Try and determine why this PoC is unacceptable before continuing to the answers.

Did you identify what makes this PoC unacceptable?

Go to the next slide for the answers.

Features of an Unacceptable Plan of Correction

The responses below the facility submitted are inadequate. Therefore, they will be unacceptable.

Acceptable Plan of Correction

Here is an example of a facility's proposed PoC that would be considered acceptable.

Note: This deficiency and evidence will be summarized as before, and the facility's proposed PoC follows. This time the PoC would be considered acceptable.

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

Deficiency Summary

The facility received a deficiency for W154 §483.420(d)(3), Staff Treatment of Clients.

The facility must have evidence that all alleged violations are thoroughly investigated.

This requirement was not met as evidenced by:

Based on interviews and record reviews, the facility failed to ensure that the documentation of facility investigation reports reflected that all serious injuries of unknown origin were thoroughly investigated for 9 of 11 reported serious injuries of unknown origin involving seven individuals (Individuals # 14, 38, 44, 45, 49, 56, and 69).

The facility failed to ensure that the documentation of incident reports reflected that all non-serious injuries of unknown origin were thoroughly investigated for 88 of 105 reported injuries of unknown origin involving 66 individuals.  

Deficiency Summary (cont'd)

A summary of specific relevant evidence noted by the surveyor includes:

• The 88 injuries of unknown origin involving 66 individuals (nine of whom had serious injuries) were not thoroughly investigated. Surveyors provided specific evidence to support each instance.
• The facility investigator stated that facility investigation reports do not mention staff interviewed who had no input as to injury cause. The investigator further stated he felt that IDT investigation findings were adequate.
• The quality assurance (QA) specialist confirmed that investigations of unknown-non serious injuries do not include interviews with staff to attempt to determine cause and/or rule out/confirm abuse/neglect. Further, the QA specialist stated that the assistant unit director (AUD) is responsible for unknown, non-serious injury investigations.
• The AUD stated that observation notes are reviewed for these types of injuries and that interviews with staff are rarely part of the process.
• The assistant superintendent for programs revealed that investigation findings typically only restate information contained in the incident report

The facility proposes the following PoC.

Note: The third column will be filled out for you on the next slide. Try and determine why this PoC is unacceptable before continuing to the answers.

The facility will ensure that the documentation of investigation reports reflects that all injuries of unknown origin are thoroughly investigated, as evidenced by --

Required PoC Element

Facility's Response

Acceptable Response

First element, " PoC must contain the plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited."

The incomplete investigations for non-serious injuries of unknown cause have been reopened. There was not a system in place to ensure thorough investigations.

Persons responsible: the facility director and director of quality services management (QSM)

Second element, "PoC must contain the procedure for implementing the acceptable PoC for the specific deficiency cited."

The Preliminary Investigation Report for Injuries of Unknown Origin will be revised to ensure a more complete investigation and will be used when investigating non-serious injuries and injuries of unknown origin.

Unit directors (UDs), assistant unit directors (AUDs), management supervisors, campus coordinators, and the nurse manager for the facility will be in-serviced of the revision.

Persons Responsible: facility director and director of medical services.  

Third element, " PoC must contain the monitoring procedure to ensure that the PoC is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements."

The facility director will conduct a monthly meeting with UDs/AUDs to critique investigations with regard to completeness.

If an injury report with a non-serious injury of unknown cause has not been investigated within 2 working days, the safety officer will notify the appropriate UD for action. Quality assurance staff will randomly monitor investigations for completeness. Any problems will be referred to the facility director for corrective action.

Persons Responsible: facility director and director of QS

Fourth element, "PoC must contain the title of the person responsible for implementing the acceptable PoC."

The QSM will be responsible for ensuring the implementation of the PoC.

Did you identify what makes this PoC acceptable?

Go to the next slide for the answers.

Features of an Acceptable Plan of Correction

The responses the facility submitted below are adequate so their PoC would be acceptable.

Section 4: Plan of Correction Submission and Onsite Follow-up Visits

Submission Time Frames

The actual CMS 2567 or Form 3724 will not be presented to the facility at the exit conference. However, surveyors will present sufficient information regarding problem areas to enable the facility to begin developing a PoC.

A provider can submit the Statement of Deficiencies (CMS 2567) or Statement of Licensing Violations form (Form 3724) with the PoC electronically. The provider can begin this process by contacting the regional survey office.  

he facility must submit an acceptable PoC within 10 calendar days of receipt of the CMS 2567.

The facility must submit an acceptable PoC within 10 working days of receipt of the Form 3724.  

Submission Time Frames (cont'd)

Licensed ICFs/IID may submit their PoCs using Form 3724 and CMS 2567 at the same time. If submitted within the shorter time frame of 10 calendar days after the date the facility receives the forms, both forms will be considered timely.

If a licensed ICF/IID submits a PoC on the CMS 2567 form beyond 10 calendar days, it will be considered late.

Conversely, if a facility waits and submits both forms according to the state requirement on the 10^th working day, then the CMS 2567 form will be considered late, resulting in possible consequences.

The facility is encouraged to submit its PoC and implement the corrective action as soon as possible. See Provider Letter 08-29.

Consequences

Failure to submit a PoC, or failure to submit an acceptable PoC, within specified time frames could result in vendor hold and/or termination of the provider agreement.

Administrative penalties may be assessed for licensed ICFs/IID.

If the facility fails to submit a PoC, the regional survey office will contact the facility to determine why the facility did not submit the PoC.

If the region determines that the facility's reason for failing to submit a PoC is unacceptable, the regional survey office will follow the procedure for unacceptable PoCs.

Regulation Services' Determination

Whether the PoC is submitted in the allotted time or not, Regulation Services will determine whether the PoC is acceptable. If the PoC is unacceptable, the facility will then have an opportunity to submit a revised PoC.

If a facility submits an unacceptable PoC, the regional survey office will contact the facility to convey the following:

• the reason the PoC was unacceptable;
• the title of the person responsible for implementing the corrective action; and
• a statement that failure to submit an acceptable PoC within the specified time frame could lead to more stringent actions

Being acceptable means that the four elements are included as a part of the PoC for each deficiency.

If this requirement is not met, administrative penalties could be assessed.

Additional Time for Submission

A facility administrator can request additional time to develop a PoC.

HHSC may ask that the plan be completed as precisely as present information permits and that it be followed by a more specific plan as early as possible.

The agency will not amend a PoC without the facility's concurrence (SOM 2728B).

Informal Dispute Resolution

If the facility chooses to refute deficiencies/violations, it can request an Informal Dispute Resolution (IDR). 

A refutation submitted on the statement of deficiencies/violations is not an acceptable PoC.

The facility is still required to submit an acceptable PoC, even if requesting an IDR.

If the facility is contesting deficiencies/violations and is considering whether to delay sending in the PoC until the dispute is resolved, the facility is taking a risk because:

• enforcement process will continue even without an acceptable PoC; and
• actions such as vendor hold and/or enforcement may be recommended for failing to submit an acceptable PoC within specified time frames

Other Plan of Correction Issues 

It is possible for facilities 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 PoC.

Below is an example of multiple CMS 2567s.

On a complaint investigation, W159 was cited.  Three months later, at the annual recertification survey and licensing inspection, W159 was re-cited and noted to be uncorrected.

One CMS 2567 will be generated for the follow up to the complaint investigation, and another one will be generated for the annual recertification survey and licensing inspection. A PoC will be required for both of the CMS 2567s; however, the facility can use the same PoC for both CMS 2567s.

Facilities need to ensure that they received all the pages of the CMS 2567 and 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. 

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

Note: The PoC for each citation must include all four PoC elements. 

On-Site Follow-Up Visits

Since the survey process focuses on the care of the individual, onsite follow-up visits are conducted to ensure that violations/deficiencies have been corrected.

Regulation Services staff will follow up on all deficiencies cited on the CMS 2567 and all violations cited on Form 3724, including the State Standards for Participation (S tags).

The purpose of the follow-up visit is to confirm that the facility has regained compliance and has the ability to remain in compliance.

The facility can show evidence of monitoring by summarizing what steps it has taken to ensure the deficient practice remains corrected.

Summary

PoCs must reflect system corrections, not just correction of examples cited on the CMS 2567 form, Form 3724, or State Standards for Participation.

The PoC should include a(n):

• proactive process or action to identify system failure;
• proactive intervention or action the facility will develop/revise and implement to address the issues;
• ongoing system to evaluate the effectiveness or progress of implemented systems;
• responsible person who will be held accountable for the system/actions; and
• responsible person who will be held accountable for evaluating the effectiveness of the implemented systems.

The Plan of Correction as a Management Tool

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

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

Therefore, it is important that all staff learn the state licensure requirements, the federal certification requirements, and the State Standards for Participation within their areas of responsibility.

Staff knowledge and individual responsibility are key factors in achieving and maintaining compliance.

The Plan of Correction as a Management Tool (cont'd)

Participation in the CMS programs mandates that facilities take the initiative and responsibility for monitoring their own performance so that they are always in compliance.

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

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

More than Correcting Deficiencies

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 and determine the underlying problem that generated the deficiency/violation.

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

When a system or part of the system is not working, it is the facility's responsibility to recognize and correct the problem, preferably before the survey team identifies a deficient practice.

When a deficient practice is identified and cited, the provider is required to correct the identified deficient practice and ensure that it does not reoccur. 

Conclusion

The importance of developing a good, acceptable PoC cannot be over-emphasized.

Submitting and following an acceptable PoC goes a long way toward ensuring continued quality care for the individuals receiving the facility's services. 

Contact

For questions or more information contact:

HHS LTC Regulation Services

Policy, Rules and Training Unit

512-438-3161

Texas Health and Human Services website