Writing Acceptable Plans of Correction
Nursing Facilities

Writing Acceptable Plans of Correction

for Nursing Facilities

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Introduction

 

In order to provide long-term care for Texans, nursing facilities must demonstrate compliance with state licensing requirements and federal certification requirements.

 

 

 

 

 

However, compliance is not a one-time event that happens during survey. At the time of the survey, Health and Human Services Commission (HHSC) assesses both your compliance with the requirements and your ability to remain in compliance.

 

 

If the facility is not in compliance, HHSC assesses whether you have a plan to correct any identified deficiencies and if your plan will prevent reoccurrence of the deficiency.

 

Objectives

In this course, we will:

 

Review the components of the Statement of Deficiencies.

 

 

Describe what Health and Human Services Commission (HHSC) Long-term Care Regulation (LTCR) requires in a PoC.

 

 

 

Identify PoC submission requirements.

 

Understanding the Statement of Deficiencies

When the provider fails to meet a requirement, HHSC will issue a statement of violation or statement of deficiencies (for certified facilities) that details the specific violation.

 

Violations and deficiencies contain the following components (hover over each term for more information):

 

Regulatory Reference

Deficient Practice Statement

Relevant Findings

Understanding the Statement of Deficiencies

Not all citations pertain to a specific resident or client. For example, if the air conditioning is not working, or the facility has not screened staff for tuberculosis, these failures will not involve a specific resident but they could affect all residents.

 

In that case, you must explain what actions you took to correct the violation (such as repairing the air conditioning or getting staff screened for tuberculosis).

 

 

 

 

 

Many other citations do refer to specific residents in the evidence. Since survey documents are public record, residents are referred to by a letter or number to protect their privacy. Specific identifiers are provided with the final survey report.

Determining the Root Cause

Before the facility can make a plan to correct the problem, it must first understand the root cause of the problem.

 

 

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Root Cause

   

Determining the Root Cause

tree with roots

The PoC process mandates that facilities develop and implement policies and procedures to remedy deficient practices promptly and to ensure those corrections are lasting. 

Sometimes, the immediate correction is obvious. If there is a hole in the wall, you fix it. If a plan of care has not been written, you write it.

When the facility understands the root cause of the deficient practice, it can develop solutions and sustain compliance.

Deficient practices are caused by either a systemic or discrete problem. Let's review these terms in detail.

 Systemic Problems

 

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

Systemic Problems

A systemic problem requires a PoC that describes:

•changes in the existing system that the facility will make to fix the problem; or

•plans for the development and implementation of a new system.

 

Systemic problem determining questions:

•Is there an existing facility policy in place to prevent the problem?

•What current process is in place to address the problem?

•Are multiple residents affected by the problem?

•Does the problem reoccur with staff of different responsibilities, during various shifts?

connected gears in a machine

  Discrete Problems

Surveyor looking at a clipboard

Discrete problems may be more difficult to identify. Discrete problems may occur within a system but only affect a small part of the entire system.

 

When there are minor or few problems within a system, then the deficiencies could be related to a discrete problem.

  

Discrete problem determining questions:

•Is this an isolated case?

•Is the problem an isolated case that stems from a larger facility problem?

•Does the problem occur during a certain shift?

•Does the problem occur at a specific location?

Plan of Correction Criteria

 

Each PoC must address the following areas as prescribed by §554.2004(e) and Chapter 7, Section 7314 of the State operations Manual.

There are five criteria required for writing an acceptable PoC:

Address what corrective action the facility will take for the residents affected by the deficient practice.

 

Address how the facility will identify other residents who could be affected by the same deficient practice.

 

 

Address what measures or systemic changes the facility will implement to ensure the deficient practice will not recur.

 

 

Indicate how the facility will monitor the corrective action to ensure the deficient practice is corrected and the solution sustained.

 

Include dates for when the corrective action will be completed.

 

 Applying the Criteria

 Now let's apply the five criteria to a deficient practice:

Suppose the facility receives a deficiency for failing to prevent and assess pressure ulcers. Evidence reveals the facility failed to prevent and assess pressure ulcer development on residents #1, #5 and #9.

 

Review: Systemic or Discrete?

Let's review root cause by illustrating systemic and discrete problems as they apply to our deficiencies:

 

The initial evidence reveals pressure ulcer deficiencies for three different residents.

 

Suppose the evidence cited in the deficiencies contains interviews with residents and staff indicating these three residents refused wound care treatment on consecutive days due to discomfort with the same staff member who provides care to all three residents. Record reviews indicate the residents had been briefed on the importance of repositioning per the physician's orders, and interviews with the DON indicate the agency is fully staffed.  In separate interviews with the residents, the terms "creepy", "odd", and "just plain weird" are used to describe this one staff member.  This is most likely a discrete problem related to one staff member.

 

 

In contrast, suppose the evidence cited in the deficiencies contains interviews with residents and staff indicating staff are not repositioning residents frequently enough in order to prevent pressure ulcers from developing, and records indicate staff have not been trained on the residents' care plans and the needs of each resident. This could be a systemic problem.   For the rest of this example, we will proceed using this scenario.

 

 

 

How will you correct the issue?

Criterion 1:

How will you correct the deficient practice for those residents identified in the deficiency?

 

The first step is to address the immediate situation for the residents. Your Plan of Correction must include what actions you will take for residents #1, #5 and #9.

 

 

Example:

The wound treatment nurse reassessed Residents #1, #5 and #9 and notified the physician. Their care plans were updated to include wound treatment on a daily basis as ordered by the physician.

 


  • Complete new assessment?
  • Revise care plan?
  • Train staff?
  • Write policy?
  • Increase staff?
  • Buy equipment?

 

 How will you identify others at risk?

Criterion 2:

How will you identify other residents who could be affected by the deficient practice?

 

 

Example:

The wound treatment nurse will interview nurse aides and examine each resident on a weekly basis to determine if any new skin breakdown has developed.

f

All residents are at risk of developing skin breakdown, especially non-ambulatory residents.

What will you do for prevention?

Pressure Ulcer Deficiency graphic

Criterion 3:

What measures or systemic changes will you implement to ensure the deficient practice won't recur?

 

 

This component requires you to examine your systems—remember, the goal is to address the root cause of the violation.

 

How will you monitor the corrective action?

Criterion 4:

How will you monitor the corrective action to ensure the deficient practice has been corrected and won't recur?

 

 

 

 

 Note: Staff who contribute to a deficient practice should not be solely responsible for implementing the corrective actions, nor for monitoring the corrective process.


Monitoring activities might include:

  • Observing staff performance
  • Conducting resident and family interviews
  • Auditing records
  • Performing quality assurance surveys
  • Reviewing incidents
  • Tracking patterns and trends
  • Conducting scheduled rounds

 

 

When will the correction be completed?

Criterion 5:

When will the corrective action be completed?

 

In general, deficiencies involving health and safety must be corrected as soon as possible.

Each PoC must include the specific date by which the correction will be completed. The corrective date must be at least one calendar day after the exit date. In most instances, the corrective date must be no more than 45 calendar days after the exit date. An example is provided in the activity below.

Note: Staff who contribute to a deficient practice shoud not be solely responsible for implementing the corrective actions, nor for monitoring the corrective processes.

Why is this PoC acceptable?

 

 

Our example PoC meets the five criteria and specifically addresses each criterion by:

What if the PoC involves training staff?

If your PoC involves training, identify:

•Who will conduct the training?

•What will the training include?

•When and how often will the training occur?

•How will you monitor the effectiveness of the training?

 

Identify the staff person/position responsible for any actions or processes you implement. For example: Who will monitor or who will train?

 

Remember - Staff who contribute to a deficient practice should not be solely responsible for implementing the corrective actions, nor for monitoring the corrective processes.

 

 

   

 

Every Citation Needs a PoC!

Essentially, HHSC needs to know - Did you correct the deficiencies, and will that correction result in continuous compliance?

You must include the 5 elements of the PoC.

 

You must produce an acceptable PoC for each deficiency cited. So, if your statement of deficiencies includes more than one citation, you must write a PoC for each citation.

 

It is possible for facilities to receive multiple survey documents, such as for an annual survey, a complaint investigation and/or a follow-up visit.

 

The documents may include the same (or different) citations. Each document you receive that includes a citation requires you to submit a PoC.

 

 

 

 

Submission Time Frames

You should return all the pages of the statement of deficiencies, including any blank last pages, with your PoC submission

 

An administrator (or other authorized official) must sign and date the PoC.

 

Although the statement of deficiencies won't be given to you at the exit conference, the surveyors will give you enough information to enable you to being developing the PoC.

 

HHSC encourages you to submit and implement the PoC as soon as possible.

 

It's also important to note that, if HHSC has recommended penalties as an enforcement action, the longer it takes to correct the violation, the higher the potential amount of the penalty imposed.

picture of a person at a computer

 

picture of a calendar with a date marked

Certified facilities must submit an acceptable PoC within 10 calendar days after the receipt of the statement of deficiencies, which satisfies both federal and state requirements.

 

Non-certified facilities must submit an acceptable PoC within 10 working days after the receipt of the statement of deficiencies to satisfy state requirements.

What if I plan to appeal?

You have the right to appeal individual citations through Informal Dispute Resolution (IDR).

 

However, you are required by law to submit a PoC and to implement an acceptable PoC regardless of what happens during the appeal.

 

Implementing a PoC does not mean you agree with the citation. Failing to submit an acceptable PoC will lead to additional enforcement action.

 

The enforcement process will continue with or without an acceptable PoC. fffff

 On-site Revisits

Surveyors follow a standard revisit protocol. As part of the revisit, you must be prepared to demonstrate the actual correction of all deficiencies and the date(s) on which the corrections occurred.

 

Learn More: On-site Revisit

  

 

PoC Effectiveness

 

 

Question: What if the facility submits an acceptable PoC but is cited for the problem again? Should the facility submit the same PoC for this reoccurrence of the problem?

 

Revision needed graphic

Answer: No. Given that the original PoC was implemented, and the problem happened again (after the training, after the monitoring), the original solution will not prevent the deficient practice from reoccurring. In this instance, it's time to dig into the root cause and try a new approach. 

 

PoC vs PoR

Question: Is the PoC the same thing as a PoR?

 

question marks

Answer: No.

Plans of Correction (PoC) are the plans facilities create to address and correct the deficiencies that are documented on the 3724. 

 

A Plan of Removal (PoR) is developed by the facility to describe how the facility plans to remove an immediate jeopardy (IJ) situation.  There is a training titled Plan of Removal on the LTC Provider Web-based Training webpage.  (Click on the titles to access the pages.)

 

 

 

Thank you for participating!

Congratulations, you have completed the "Writing Acceptable Plans of Correction" training.

smiling person

The POC is a valuable management tool that can help you:

  • Achieve and maintain compliance
  • Prevent recurring deficiencies.
  • Make changes that improve care delivery
  • Improve your operations

 

 


 

For questions or more information please contact:

HHSC Long-term Care Regulation

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.

 

 

 The next slide contains information on how to sign up for GovDelivery.

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The Texas Health and Human Services Commission contracts with a company called Granicus to provide email updates, called GovDelivery. 

GovDelivery is a web-based e-mail subscription management system that allows a member of the public (like you!) to subscribe to news and information on HHSC websites. Here's where GovDelivery users can select specific topics that interest them.

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