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Writing a Plan of Correction

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Writing a POC

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Writing a POC

POST-TEST

1. Which of the following timelines are incorrect?

a. 1st revisit between last date on the POC and 60th

b. 2nd revisit no later than 155th-165th day

c. 3rd revisit must be approved by Regional office

d. None of the above

2. Which of the following are required when denial of payment sanctions are imposed?

a. No steps are required

b. Notify verbally at a resident council meeting

c. Notify in writing reasons, resident’s liability, and Part A may be available at another SNF


3. An acceptable POC includes which of the following?

a. Title of person responsible

b. How corrective action will be accomplished for residents that were cited

c. Procedures for implementing the plan

d. All of the above

4. Which statements apply to best practices for POC?

a. It is OK to admit fault

b. Do not allege compliance unless in compliance

c. Generic disclaimers are not acceptable

d. All of the above

5. Is the following statement True or False?

a. There are four required components of a POC


Writing a POC

POST-TEST - ANSWERS

1. Which of the following timelines are incorrect?

a. 1st revisit between last date on the POC and 60th

b. 2nd revisit no later than 155th-165th day

c. 3rd revisit must be approved by Regional office


D

2. Which of the following are required when denial of payment sanctions are imposed?

a. No steps are required

b. Notify verbally at a resident council meeting

c. Notify in writing reasons, resident’s liability, and Part A may be available at another SNF


C

3. An acceptable POC includes which of the following?

a. Title of person responsible

b. How corrective action will be accomplished for residents that were cited

c. Procedures for implementing the plan

d. All of the above

D

4. Which statements apply to best practices for POC?

a. It is OK to admit fault

b. Do not allege compliance unless in compliance

c. Generic disclaimers are not acceptable

d. All of the above

B

5. Is the following statement True or False?

a. There are four required components of a POC

T


Time Lines

• Termination date in first letter

– Immediate Jeopardy (J, K, L): no more than 23 days to correct before termination

– Noncompliance: 180 days to correct before termination

POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com©

– Will include dates for Civil Money Penalties (CMP) or Remedies

3

Time Lines

• 1st revisit following a survey with non-compliance-between the last date on the plan p pof correction and the 60th day.

• 2nd visit following continuing non-compliance –Generally no later than 155th and 165th day following initial survey date


following initial survey date.

• 3rd revisit following survey with non-compliance – Regional office must approve.

4



5

Remedy Categories• Category 1 Least Severe

– Directed plan of correction Category 3 Most Severe– State Monitor

– Directed in-service training• Category 2 Moderately Severe

– Denial of payment of new admissions - MedicaidDenial of payment for all

Severe– Temporary Management

– Immediate Termination

O i l Ci il


– Denial of payment for all –Medicare/Medicaid imposed by CMS

– Civil Money Penalty: $50--$3000• New for immediate jeopardy-up to

$10,000/day

– Optional Civil Money Penalty:

$3050-$10,000/day

6


Least Severe Remedies

• Directed POCFi l i d i b k– First letter states required actions to be taken

• Directed In-Service– First letter will state if a Directed In-service is

required • State Monitor – oversights POC


g– State approved person is required to oversight

plan of correction

7

Moderately Severe Remedies

• Denial of PaymentState for Medicaid & CMS for Medicare– State for Medicaid & CMS for Medicare

– Applies to new admits or readmits even if discharged prior to effective date. • If admitted on or after sanction, take a Temporary

Leave of Absence, then sanctions apply but not considered a new admit.


– Private pay admission after sanction, if becomes eligible for Medicare or Medicaid, the sanction applies.

8



• Denial of Payment continued: y

• SNF must notify beneficiary that sanctions have been imposed and impact on benefits

– In writing

– Reason for sanctions

Beneficiary’s liability for cost of SNF services during


– Beneficiary s liability for cost of SNF services during ban

– Med Part A may be available at another SNF

9


• Civil Money PenaltiesCivil Money Penalties

– 50-$3000 dollars per day/per instance

– Applies to deficiencies that are not Immediate Jeopardy


10


Severe Remedies

• Temporary Management– Oversights POC but also has right to hire, terminate,

manage funds and change procedures

• Termination– Relocation of residents

• Optional CMP


Optional CMP– $3050-$10,000

– For Immediate Jeopardy

11

Self-Reported Noncompliance

• Self-Reported Noncompliance-N li h i d b f iliNoncompliance that is reported by a facility to the State Survey Agency before it is identified by the State, CMS, or reported to the State or CMS by an entity other than the facility itself.

• CMS will reduce a civil money penalty by 50


y p y ypercent when a facility self-reports and promptly corrects a deficiency for which a civil money penalty is imposed by CMS

12


Additional Steps for Substandard Care Citations

1. Resident Behavior and Facility Practicesy

F-tags 221-226

2. Quality of Life F-tags 240-258

3. Quality of Care F-tags 309-333

If f h b F i d d


If any of the above F-tags are cited at a scope and severity scale of F, H, I, J, K, or L - facility is in

substandard care

13

Additional Steps for Substandard Care Citations

• Automatic steps if Substandard Care

L bili id NATCEP (N Aid– Lose ability to provide a NATCEP (Nurse Aide Training and Competency Evaluation Program) for two years if it

• Has been subject to an extended survey.

• Has been assessed a CMP of not less than $5000,

O bj d i l f T


• Or subject to denial of payment or Temp. management

• This determination can be reviewed/appealed.

• State may waive disapproval of programs offered in (not by) if no other is available and oversight in place.

14


Additional Steps forSubstandard Care Citations

• Automatic steps if Substandard Care

– Administrator’s Licensing board is notified

• Applied against their license

– For residents identified with Substandard Care; submit names of Physicians for

tifi ti


notification

– Starts cycle of Poor Performing facility

– You can dispute Substandard Care S/S15

Opportunity to Correct

• Mandatory criteria for having “No Opportunity” to Correct before remedies are imposedto Correct before remedies are imposed.

– Repeat citation at G or higher.

• Most states focus on repeat of same F-tag but the rules are not clear.

– Previously terminated NF, now having deficiencies i l h fi f i


causing actual harm on first survey after re-entry into program

– IJ citations

– Noncompliance with Per Instance CMP16


CMS 2567

• Provider has following three optionsAccept the deficiencies stated on 2567 and– Accept the deficiencies stated on 2567 and submit a POC;

– Record objections to cited deficiencies on 2567 AND submit POC;

– Record objections to cited deficiencies on


2567, do not submit a POC, instead provide convincing arguments and documented evidence that the deficiencies are invalid.

– Rarely used very risky 17

Plan of Correction (POC)

• Plan of correction must meet four criteria1. How the corrective action will be

accomplished for those residents found to have been affected by the deficient practice.


2. How the facility will identify other residents having the potential to be affected by the same deficient practice.

18


Plan of Correction

• Plan of correction must meet four criteria3. What measures will be put into place or systemic3. What measures will be put into place or systemic

changes made to ensure that the deficient practice will not recur.

4. How the facility will monitor its correctiveactions to ensure that the deficient practice is


being corrected and will not recur, i.e. whatprogram will be put into place to monitor thecontinued effectiveness of the systemic changes.

19

Plan of Correction

Plan of correction must also include:

• I l d d t h rr ti ti ill• Include dates when corrective action will

be completed.

• The corrective action completion dates must be acceptable to the State.

• If the plan of correction is unacceptable for


• If the plan of correction is unacceptable for any reason, the State will notify the facility in writing.

20


Plan of Correction

• Facilities should be cautioned that they are ultimately accountable for their ownultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely. The plan of correction will serve as the facility’s allegation of compliance.


serve as the facility s allegation of compliance.

21

Plan of Correction

• Acceptable plan of correction includes:

– The plan for correcting the deficiency.

– Procedures for implementing the plan.

– Monitoring procedure to ensure the PoC is effective and deficiency remains corrected

d/ i li


and/or in compliance.

– The title of the person responsible.

22


Plan of Correction Tips

• Indicate dates by which corrective action will be completed most within 60 days p y– Completion dates should be a few days ahead of

date certain for remedies– Be realistic; don’t say “all”

• Do not admit fault– Statements such as “will continue to…”


• Do not imply fault – “All assessments will be redone” – “Going forward …..”

23

Plan of Correction Tips

• Do NOT allege compliance unless in• Do NOT allege compliance unless in compliance

• Be realistic regarding ongoing QA • Include Directed Inservices in POC• Surveyors will survey from date of Alleged


Compliance until date of re-survey

24


Plan of Correction

• Consider a Generic Disclaimer – “This plan of correction is submitted as requiredThis plan of correction is submitted as required

under State and Federal law. This plan does not constitute admission of liability on the part of the facility and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors’ findings or conclusions are accurate


surveyors findings or conclusions are accurate, that the findings constitute a deficiency or that the scope or severity regarding of the deficiencies cited are correctly applied.”

25

Plan of Correction

• Consider a Generic Disclaimer

– “This plan of correction is submitted as required under state and federal law. The provider maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character so as to


ylimit the providers’ capacity to render care.”

26


Plan of Correction

• Consider a Generic Disclaimer “P i d i f hi l f i i– “Preparation and execution of this plan of correction in no way constitutes an admission or agreement by “facility” of the truth of the facts alleged in this statement of deficiency and plan of correction. In fact, this plan of correction is submitted exclusively to comply with state and federal law. “Facility” reserves the right to challenge in legal


proceedings, all deficiencies, statements, findings, facts, and conclusions that form the basis of the stated deficiency. This plan of correction serves as the allegation of compliance.”

27

Plan of Correction

• May start a specific F-tag with a disclaimer e.g. “All residents have and will continue to be assessed forresidents have and will continue to be assessed for pressure ulcer risk factors to develop a comprehensive care plan.”

• Dietary: “It is our policy to store, prepare, distribute, and serve food under sanitary conditions.”

• Accidents: “It is our policy that the environment


• Accidents: It is our policy that the environment remain free of accident hazards as is possible.”

28


1. How the corrective action will be accomplished for

Plan of Correction

pthose residents found to have been affected by the deficient practice

• Address each Resident by number.

• State what was done and completion date.


p

• Completion date is usually already passed.

29

2. How the facility will identify other residents having the potential to be affected by the same

Plan of Correction

having the potential to be affected by the same deficient practice

• May required a statement that “all residents are at risk to be affected.”

• Could be more focused:

All r id t ith rr t pr r l r ill b


– All residents with current pressure ulcers will be reviewed.

– All resident on antipsychotics…..

– All residents inability to communicate needs…30


3. What measures will be put into place or systemic changes made to ensure that

Plan of Correction

gthe deficient practice will not recur.• May include:

– P&P review and revisions as needed.– Inservice in general – Training or counseling/firing


g g/ g– Change in process or procedures e.g. Review at daily

stand-up– Only list changes that you are really willing to

implement 31

4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and

Plan of Correction

ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic changes.

• Include who is assigned this step.• Try not to over commit.


• Indicate oversight for implementation of steps and QA until stable. Do not need to imply QA will continue forever when focused QA is initiated.

• Try to integrate into ongoing QA that you already perform. 32


Presentation of Evidence

• Several methods are available:

Attach any inservice or contracts or work orders if– Attach any inservice or contracts or work orders if done prior to the 2567 being sent in.

– Create a PoC manual

• Separate out each F-tag

– With each F-tag include documentation that i l l d


supports action plan was completed

– Sample QA forms.

» Do not share completed audits unless absolutely necessary during revisit.

33

Removal of Immediate Jeopardy

• Start correction immediatelyy

• Attempt to remove before exit

• Requires onsite confirmation to remove

• Submit “allegations of removal” for re-visit


34


Removal of Immediate Jeopardy

• Sufficient information to show:

– How the IJ was removedHow the IJ was removed

– The date was removed • The state may not be as timely as the SNF would like

in terms of actual date onsite.

– 2567 may be deferred until removed

Surveyors may complete 2567 after removal


– Surveyors may complete 2567 after removal

• IJ removed but deficient practice present

– Changes to 90 day termination

35

Informal Dispute Resolution (IDR)

• IDRs may NOT be used to challenge

– Clarification of deficienciesClarification of deficiencies

– Challenge Scope/Severity

• However, can be used to challenge substandard care or immediate jeopardy scope/severity.

– Remedies imposed


– Complaints that survey team did not follow procedures

– Allegations of inconsistent findings

– Alleged inadequacy of IDR process. 36


IDR

• May IDR a deficiency from a Revisit Survey if h f ll ithe following occurs:

– Continues to cite a F-tag cited during first survey

– New F-tag cited


37

Independent Informal Dispute Resolution (IIDR)

• Alternate opportunity to dispute deficiencies when CMP are imposed p

• Performed by an Independent of State Survey entity within government or outside entity

– Entity Approved by CMS

• State must offer IIDR within 30 days of CMP.

F ilit t t IIDR ithi 10 d


– Facility must request IIDR within 10 days

• Must be completed within 60 days of request.

• Cannot by used after decision made by IDR; unless CMP were issued after that decision.

38



• IIDR may not be used to challenge:Clarification of deficiencies– Clarification of deficiencies

– Challenge Scope/Severity

• However, can be used to challenge substandard care or immediate jeopardy scope/severity.

– Remedies imposed


– Complaints that survey team did not follow procedures

– Allegations of inconsistent findings

– Alleged inadequacy of IDR or IIDR process. 39


• May IIDR upon Revisits for the following:

– Continue to cite a F-tag cited during first survey with continuation of CMP

– New F-tag with CMP

• Will notify resident/rep and Ombudsmen for t


comments.

• FINAL DECISION- made by State.

40


Appeal Process

• Consult with legal counsel• File notice of appeal within 60 days after receipt ofFile notice of appeal within 60 days after receipt of

CMS notice imposing CMP• Submit request for expedited hearing in termination

case• Request for hearing must include:

– Specific survey issue the facility is disputingSp ifi d fi i b i di p t d


– Specific deficiency being disputed– Remedies being appealed– Reasons why believe remedy is inappropriate Gather clinical documentation, interview

witnesses etc. 41

Plan of Correction

• Always create a realistic plan

• Do not admit fault

• Consider Disclaimer statements

• Create PoC Manual to keep track of action steps


Good luck!

42


SCOPE AND SEVERITY GRID

IMMEDIATE JEOPARDY To Resident Health or Safety

PoC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2 Substandard Quality of Care J

PoC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2 Substandard Quality of Care K

PoC Required: Cat. 3 Optional: Cat. 2 Optional: Cat. 1 Substandard Quality of Care L

ACTUAL HARM That is not Immediate Jeopardy

PoC Required: Cat. 2 Optional: Cat. 1 G

PoC Required: Cat. 2 Optional: Cat. 1 Substandard Quality of Care H

PoC Required: Cat. 2 Optional: Cat. 1 Optional: Temp. Mgmt. Substandard Quality of Care I

NO ACTUAL HARM with POTENTIAL FOR MORE THAN MINIMAL HARM that is not immediate jeopardy

PoC Required: Cat. 1 Optional: Cat. 2

D



standard Quality of Care F NO ACTUAL HARM with POTENTIAL FOR MINIMAL HARM

No Plan of Correction No Remedies Commitment to Correct Not on CMS-2567

A

PoC

C

C

ISOLATED PATT

WIDESPREAD

Substandard Care – if F221-225, F240-258, F309-333

Remedy Category 1

Directed Plan of Correction: State Monitor: And/or Directed In-service Training

Remedy Category 2 Denial of Payment for New AdmissionDenial of Payment for All Individuals:Imposed by CMS And/or Civil Money Penalties $50-$3,000/day

FH60 - Developed by Polaris Group www.polaris-group.com

E Sub

B

Po

ERN

s:

Remedy Category 3 Temporary Management: Termination Optional: Civil Money Penalties $3,050-$10,000/day

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