Unacceptable Plan of Correction
We will now look at an example of a deficiency a facility received and the unacceptable PoC they proposed.
As you read, take note of some of the reasons the PoC would be considered unacceptable.
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 individual.
This requirement was not met as evidenced by:
Based on observations, interviews, and record review, the facility failed to ensure that the individualized skills and socialization (ISS) center met an individual's need for purposeful activities for 1 of 1 individual reviewed for using an ISS center (Individual #1).
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 an ISS 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 ISS center. He did not receive the specified training during the observation.
Exit date 06/15/XX.
Now, let’s look at the proposed PoC.