Corrective Action Plans

1. Corrective Action Plans A Guide To Completion and Progress Reporting to DMA

2. An illustration� The following slide is an illustration of what the new form looks like.

4. Basic Process: A � This number and description comes off your QA form and/or your post review letter. It identifies the deficiency/key aspect description. List both the number and the description in this column. B � What are you going to do about it specific to this patient(s) or event(s)? There will be more than 1 step/task documented here. C � What is your agency going to do to prevent it from happening with the rest of your caseload? List multiple specific tasks to be done in this column specific to other charts or events not yet found or reviewed to ensure that the problem isn�t larger than originally discovered. D � Identify the person in charge fixing the specific things identified in column C and D. List the date that each action will be completed by the person you identified in column E. E � How do you know it�s getting done? What system of monitoring did your agency put into place to ensure that the plan gets completed in its entirety and how will you monitor on an ongoing basis to ensure that the problem no longer exists or doesn�t come back.

5. Progress report The next slide illustrates the progress report. This report is the form that is completed AFTER the initial corrective action plan has been formulated. It recaps the deficiencies and what your agency did to correct the problem, then lists progress made toward the completion of the initial plan.

6. Click to add text

7. Most important questions to ask: Does it make sense? Is my plan to solve the problem really going to solve it? Is it reasonable? Is it achievable? How does it apply to the rest of my case load? Again, own the form � don�t let the form own you. Use it as a tool.Again, own the form � don�t let the form own you. Use it as a tool.

8. Things to include: Identify what happened Identify why it happened. Ask yourself why. When you can quit asking �why�, you have reached the root of the problem and then begin getting it fixed. How are you going to fix it? Who�s going to fix it? (It�s not a 1-person show) When are they going to be done fixing it? (tomorrow, next week, by the end of the quarter, etc. � not next year) How are you going to keep it fixed and keep it from coming back again?

9. More things to include: Policy & procedure changes that affect how your agency performs day to day activities Targeted audits or more frequent self-reviews to ensure that you got it licked Communication � memos, newsletters, letters to your clients, etc (just make sure you keep copies of all correspondence) If you need to pay back money, get it done. This looks REALLY good on your agency in the eyes of Program Integrity. Training, training, training! (From the ground up � your aide to your administrator; make it a requirement in orientation and make it happen more than once during employment with your agency)

10. Things to avoid: Restating the obvious; restating that the nurse will do visits on time is not appropriate. You need to state how this will take place. Piling it on one person; (share the load please) Unreasonable timelines (May 2012 is an unreasonable timeline) Poor follow through � if you write it down, make it happen. If it doesn�t work, try something else � remember the Corrective Action Plan is just a �plan� and it can change as your agency�s needs change. Just remember to update your plan so you have documentation to prove what you did.

11. What constitutes a payback? RN is not certified � any services provided to clients that this nurse assessed or supervised prior to the date she completed training and became certified is not billable to Medicaid. Supervision visits are late � anything beyond the 90th day if service has been provided is not billable until supervision is completed. PACT form does not show at least 2 deficits in ADL�s � payback from date of assessment that did not document the qualifying ADL�s.

12. What constitutes a payback? MD signature is outside of 60 day timeline - if he has not signed his verbal order within 60 days, payback every day from day 60 until the day the PACT is signed. MD order for continued service {reassessment} (verbal or written) is older than 365 days. Payback every day from day 365 until you obtain an order for service (either verbal or written). Services billed do not reconcile with what was authorized and/or provided. If you billed something outside of what the MD signed for or outside of what the aide did, it�s a payback.

23. Now that you have finished the initial plan� Submit to DMA per their given timeline in your letter. If your plan is accepted, you will be notified by DMA. You will at some point in time need to complete a progress report to them to show what kind of progress you are making toward the goals you set out in your initial plan of correction. DMA will notify you when your first progress report is due to them. The form to use looks like this�

32. More things to consider� DMA may ask you to submit your internal QA and the PACT forms along with the last month of service notes to prove that you are making a valid effort to achieve compliance. Cycles of supervision notes and service deviations may also be requested so that DMA can perform a �desk audit� of what you are doing and achieving with this plan and progress report.

33. More things to consider� If your actions are not fixing your problems, dig deeper to find out what else you can do. Revise your plan to include new or additional strategies to actually correct the problem and prevent its recurrence.

34. Now submit! This completes your corrective action plan and/or your progress reporting. Follow the instructions on the letter from DMA as to submission deadlines and return addresses. Congratulations! You and your agency are on the road to success by improving the quality of the care you provide!