Writing Acceptable PoCs for ICF
Presented by Long-term Care Regulation
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This computer-based training (CBT) was designed for both ICF providers and Long-term Care Regulation (LTCR) 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.
This training aims to promote quality of care and quality of life for individuals in ICFs.
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 the development of an acceptable PoC.
This CBT focuses on criteria that must be included in the PoC to help you determine what information is required.
Providers need to understand how PoCs are evaluated and what makes a PoC acceptable to Long-term Care Regulation (LTCR).
In this training, you will:
All ICFs are federally certified. Many are both certified and licensed by the state. Non-licensed facilities, such as state-supported living centers (SSLCs) and local intellectual and developmental disability authorities (LIDDAs), are certified only.
The state of Texas surveys ICFs to ensure the facility is in compliance with the rules and regulations.
State licensure is based on the Texas Administrative Code (TAC). 26 TAC Chapter 551 contains the ICF licensing standards.
State Standards of Participation are based on the Texas Administrative Code (TAC). 26 TAC Chapter 551 and 26 TAC Chapter 261 contain the State Standards of Participation.
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 requirements for ICF programs and the survey process.
Participation in 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 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, they will write a violation/deficiency.
Facilities should not rely on surveys or investigations to identify compliance problems.
Facilities licensed by the state of Texas must comply with 26 TAC Chapter 551 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:
A licensing violation is a failure on the part of a state-licensed facility to meet these requirements.
HHS Form 3724 is a licensure violation form for documenting failure to comply with state requirement M tags 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.
All ICFs 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 CMS Form 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, LTCR will email the HHS Form 3724 and CMS Form 2567 to the facility within 10 business days from the date of exit.
The CMS Form 2567 and HHSC Form 3724 are important because they:
Deficiencies/violations that surveyors write have three components. They are:
Keep in mind that both violations and deficiencies are called citations. Source: CMS, Principles of Documentation (POD)
The regulatory reference:
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 how 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.
Example of a Regulatory Reference
W242—§483.440(c)(6)(iii), Active Treatment Services
Include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
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:
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 2 of 6 individuals (Individuals #2 and #3).
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.
Record review of Individual #2's individual program plan (IPP), dated 7/2/XX, revealed that her dressing training objective was as follows, "Individual #2 will receive services in the areas of eating, range of motion, social, dressing, mobility, and grooming." Further review revealed that the objective did not state the criteria that Individual #2 must accomplish to achieve the objective.
Record review of Individual #2's program data folder for 7/XX and 8/ XX revealed that there were no data sheets for this program.
Record review of Individual #3's IPP, dated 3/15/ XX, revealed that her dressing training objective was as follows, "Individual #3 will improve her dressing skills by mastering two of three objectives by March 20XX." Further review revealed that the objective did not state the criteria that Individual #3 must accomplish 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/XX at 1:30 p.m. revealed that the dressing 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.
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:
Based on observation and interviews, the facility failed to prevent cross-contamination during meals for 6 of 6 individuals (Individuals #1—6).
Observations on 7/14/XX 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/ XX 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/ XX 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/ XX 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."
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.
Merriam-Webster's Dictionary defines a system as a regularly interacting or interdependent group of 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:
It is a system failure when the failure involves 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:
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:
When there are few problems within a system, the violation/deficiency may be related to a discrete problem, rather than a systemic problem. The facility must 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. For example:
At first glance, a complex situation could appear to be either a systemic or discrete failure. In such a case, the facility must examine the situation critically to determine the ultimate basis of the failure.
Once the facility fully assesses the cause of the failure and determines its type, it must take steps to correct the failure and the circumstance of its existence.
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.
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:
How would you determine whether this is a system failure or a discrete failure?
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.
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 how new systems be implemented to correct the problem.
State Operations Manual §3006.5(C)(1)(a-e) requires that an acceptable PoC must include:
The first criterion of an acceptable PoC is:
How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice.
This first criterion of an acceptable PoC needs to cover what the facility is going to do to correct the specific deficiency.
A facility's PoC should also address what processes or events led up to the deficiency. This will ensure all aspects of why the deficiency occurred are explored.
Examples:
In the situation of a facility failing to ensure quarterly evacuation drills, the PoC should address the following questions:
The following are examples of processes that could have led to the deficiency, failure to ensure quarterly evacuation drills.
Address Each Instance of Noncompliance and All Evidence
To meet the first criteria 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.
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:
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:
Note: The examples above are abbreviated and not as detailed as what should be on a CMS 2567 form or HHS Form 3724.
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.
6 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:
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.
The second criterion of an acceptable PoC is:
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.
Let’s take the example of evacuation drills. In the situation of a facility failing to ensure quarterly evacuation drills, all individuals are at risk of harm or death in the event of an emergency that requires evacuation.
The third criterion of an acceptable PoC is:
What measures will be put into place or system changes made to ensure that the deficient practice will not recur.
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 third criterion, facilities must:
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.
The following is an example of a system to address an abuse, neglect, and exploitation (ANE) deficiency:
The fourth criterion of an acceptable PoC is:
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.
For this criterion, 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:
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.
Below is an example of a facility's monitoring procedure for a deficiency for inadequately monitoring the training services at the individualized skills and socialization (ISS) center.
The administrator will verify through weekly QIDP notes that the QIDP is monitoring training and services at the ISS center.
The administrator will maintain an ISS center Log that includes specific information, such as:
Note: This is an abbreviated example.
Having a monitoring procedure will ensure that the system corrections are effective.
Example
A monitoring system a facility may establish to ensure that the system corrections are effective:
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.
The fifth criterion of an acceptable PoC is:
When corrective action will be completed. Must be at least one day past the date of exit.
For example, it may take a week to arrange pest control for an issue, or a month to train all staff on infection control. Therefore, each citation may have its own date of completion, which may differ from the dates for other citations.
Please include the date when the corrective actions will be completed. The completion date must be reasonable for the deficient practice cited but at least one day past the day of exit.
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.
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 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 Form 2567 and all violations cited on HHSC Form 3724 must be individually addressed in the PoC.
The PoC must not:
It is acceptable to use staff-designated titles, for example the:
The PoC must also be dated and signed by the administrator or other authorized official. Their title must be included (SOM 2728B).
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:
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:
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, that the plan it creates can be implemented, monitored, and followed.
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.
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:
Exit date 06/15/XX.
Now, let’s look at the proposed PoC.
The facility proposes the following PoC.
Directions:
| Required PoC Criterion | Facility's Response |
|---|---|
| Criterion 1: How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice. | A facility representative will assess Individual #1 at the Individualized Skills and Socialization (ISS) program, and his interdisciplinary team (IDT) will meet to review and discuss the findings of the assessment. Unacceptable Response Explanation |
| Criterion 2: 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. | All other individuals receive adequate services at the ISS program. Unacceptable Response Explanation |
| Criterion 3: What measures will be put into place or system changes made to ensure that the deficient practice will not recur. | At Individual #1's annual planning conference, the ISS program, staff observations, and review of client performance will be discussed. Unacceptable Response Explanation |
| Criterion 4: 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. | The administrator will ensure proper monitoring. Unacceptable Response Explanation |
| Criterion 5: When corrective action will be completed. Must be at least one day past the date of exit. | The action was corrected on the day of exit. Unacceptable Response Explanation |
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.
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:
Now, let’s look at the proposed PoC.
The facility proposes the following PoC.
Directions:
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 Criterion | Facility's Response |
|---|---|
| Criterion 1: How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice. | 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). Acceptable Response Explanation |
| Criterion 2: 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. | All individuals at the facility have the potential for harm due to this deficient practice. Acceptable Response Explanation |
| Criterion 3: What measures will be put into place or system changes made to ensure that the deficient practice will not recur. | 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. Acceptable Response Explanation |
| Criterion 4: 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. | The facility director will conduct a monthly meeting with UDs/AUDs to critique investigations regarding 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 QSM. Acceptable Response Explanation |
| Criterion 5: When corrective action will be completed. Must be at least one day past the date of exit. | The corrective action will be completed within one month of the day of exit. Acceptable Response Explanation |
The actual CMS Form 2567 or HHSC 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 Form 2567) or Statement of Licensing Violations form (HHSC Form 3724) with the PoC electronically. The provider can begin this process by contacting the regional survey office.
The facility must submit an acceptable PoC within 10 calendar days of receipt of the CMS Form 2567.
The facility must submit an acceptable PoC within 10 working days of receipt of the HHSC Form 3724.
Licensed ICFs may submit their PoCs using HHSC Form 3724 and CMS Form 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 submits a PoC on the CMS Form 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 10th working day, then the CMS Form 2567 will be considered late, resulting in possible consequences. The agency will send a failure to submit notice on the next business day after that 10th working day.
The facility is encouraged to submit its PoC and implement the corrective action as soon as possible.
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).
Failure to submit a PoC, or failure to submit an acceptable PoC, within specified time frames could result in a vendor hold and/or termination of the provider agreement.
Administrative penalties may be assessed for licensed ICFs.
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.
Whether the PoC is submitted in the allotted time or not, HHSC 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:
Being acceptable means that the five criteria are included as a part of the PoC for each deficiency.
If this requirement is not met, administrative penalties could be assessed.
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:
Facilities can 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 Form 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 Form 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 CMS Form 2567s; however, the facility can use the same PoC for both CMS Form 2567s.
Facilities need to ensure that they received all the pages of the CMS Form 2567 and HHSC Form 3724, including blank last pages. In some instances, the federal data system prints a blank last page due to the setup for the last printed line at the bottom of the previous page.
All pages, including blank pages, must be returned to the HHSC office specified in the PoC letter that accompanied the CMS Form 2567 and HHSC Form 3724.
Note: The PoC for each citation must include all five PoC criteria.
Since the survey process focuses on the care of the individual, onsite follow-up visits can be conducted to ensure that violations/deficiencies have been corrected.
HHSC staff will follow up on all deficiencies cited on the CMS Form 2567 and all violations cited on HHSC 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 can remain in compliance.
The facility can show evidence of monitoring by summarizing what steps it has taken to ensure the deficient practice remains corrected.
Providers may be asked to produce evidence for non-onsite follow-up visits as well as proof elements in the POC were completed (e.g., training documentation with staff signatures).
Question: Is a Plan of Correction (PoC) the same thing as a Plan of Removal (PoR)?
Answer: No.
A Plan of Correction (PoC) is the plan facilities create to address and correct the deficiencies that are documented on the HHSC Form 3724.
A Plan of Removal (PoR) is developed by the facility to describe how the facility plans to remove an immediate jeopardy (IJ) situation.
The POC focuses on more long-term correction whereas the PoR is more imminent issues that need to be corrected immediately to ensure health and safety.
Plan of Removal Training is available on the LTC Provider Web-based Training webpage.
The provider plays a singular role in achieving and maintaining compliance.
The provider must know the requirements based on the state and federal regulations to provide services that meet those requirements. Therefore, all staff must 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.
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:
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:
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 adjusts 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.
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.
You finished this training!
For questions or more information please contact:
LTCRPolicy@hhs.texas.gov
LTCRJointTraining@hhs.texas.gov
LTCR-FieldOperations@hhs.texas.gov
Please put your Facility name and ID in the subject line, if applicable.
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