Acceptable Plan of Correction

Now let’s look at an example of a deficiency a facility received and the acceptable PoC they proposed.

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.

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 the 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.

Now, let’s look at the proposed PoC.