Summary
PoCs must reflect system corrections, not just the correction of examples cited on CMS Form 2567, HHSC Form 3724, or State Standards for Participation.
The PoC should include:
- How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice;
- How the facility will identify other individuals having the potential to be affected by the deficient practice and how the facility will act to protect individuals in similar situations;
- What measures will be put into place or system changes made to ensure that the deficient practice will not recur;
- How the corrective actions will be monitored to ensure the deficient practice is being corrected and will not recur and who will be responsible for monitoring; and
- When corrective action will be completed. Must be at least one day past the date of exit.