Your home health agency (HHA) recently went through a survey and was cited for deficiencies, which is a common outcome nowadays. The next step is to write a Plan of Correction (POC). Instead of viewing this task as a nuisance, you should consider it an opportunity. The process of writing an acceptable POC allows you to develop a rapport with the surveyor and learn how your agency can ensure the goal of providing safe, quality care and services in compliance with the new Conditions of Participation (CoPs). In this blog we will provide further details regarding the Plan of Correction.
Defining the Plan of Correction
A Plan of Correction is a documented agency reply to a survey summary of findings (SOF) and/or summary of deficiencies (SOD), which are received ten days after an on-site agency survey by the State Agency (SA) or National Accrediting Organization (AO). A POC explains how the agency citations of noncompliance will be corrected and the process that will be implemented to prevent recurrence. A Plan of Correction is required for several reasons:
- The State requires the POC for licensure compliance.
- CMS requires a POC for federal certification compliance.
- The POC is submitted to meet established state and federal laws.
By completing the survey and certification process, CMS can evaluate compliance with the Home Health Conditions of Participation. And, an agency’s compliance with the Home Health Conditions of Participation demonstrates it is providing quality patient care and services that meet minimum health and safety standards, resulting in positive patient outcomes.
When to Write the Plan of Correction
It would seem that the Plan of Correction should begin after the survey is completed, but actually it should start during the survey process itself when the surveyor shares findings with the agency. The agency should correct any deficiencies, as applicable, while the surveyor is present. Now is the time to provide evidence of the corrected deficiency to the surveyor because the surveyor may not cite the deficiency if it is an AO standard deficiency. The surveyor must cite CoP deficiencies, but citations corrected during the survey could be considered when determining the classification of citation to be assigned.
During the Exit Conference with the surveyor, the HHA should include as many staff members as are available to attend in order to hear firsthand the findings and concerns. If possible during the Exit Conference, the State Agency or Accrediting Organization will inform the agency if a return on-site visit to evaluate the correction of deficiencies and compliance will be required. However, there are times when the surveyor will have to defer this information to the Summary Report.
Following the Exit Conference, the agency should conduct a staff meeting to gather staff input on how to correct and prevent noncompliance going forward. It is not necessary to wait for the final Summary Report before beginning the POC.
Developing the Plan of Correction should be a team effort, involving all staff members who participate in the survey process. Then administrators should share the findings with contract and other agency staff, requesting their input regarding how to correct deficiencies and prevent noncompliance in the future.
Completing a Plan of Correction
The SOF/SOD will cover the specific regulatory citations of noncompliance and the number of days the agency has to complete and submit the Plan of Correction. Typically, the POC must be submitted within 10 calendar days, but it can be fewer or more depending upon the type of deficiency and the accrediting organization (please see our previous blog for further details). After the HHA receives the SOF/SOD, additional staff meetings should be scheduled to complete the POC. If an agency is cited for a Condition-Level Deficiency, the date of compliance is usually within 10 calendar days from the date the agency received the SOF.
The State Agency or Accrediting Organization will provide the form for completing the Plan of Correction, which will provide instructions, the required components and its due date. Usually, a sample POC is provided to the HHA.
The Plan of Correction consists of five components:
- The deficiency cited
- Specific action to be taken
- Date to be completed
- Position responsible
- Process to ensure the deficit will not recur
The last four items must be completed by the agency. Any of the deficiencies cited should not be a surprise because the agency should have an understanding of each one based on the Exit Conference with the surveyor. However, if the agency needs further clarification after receiving the SOF/SOD, the SA or AO should be contacted.
Need Help and Support?
The survey process can be nerve wracking! By being prepared and having a support system for the survey process, correcting citations and developing a plan of correction to prevent recurrence can greatly improve the survey outcomes and staff experiences.
5 Star Consultants offer a wealth of experience. Every RN consultant on our team is also a former or current AO surveyor; therefore, we can guide your staff through the survey process and with the completion of the POC.
If you would like to discuss our services further, please contact us at [email protected] or 866-428-4040.