Understanding Basic Components:

1. Understanding Basic Components: A Plan of Correction

2. Objectives • Understand the need for a clear and concise POC • Identify the basic components of a POC • Write an acceptable POC

3. Why is a POC Needed? • Provide a detailed outline of the facility’s plan to achieve and maintain compliance • Assists surveyors in determining the status of implemented corrective actions • Utilized by surveyors in revisit offsite preparation

4. Why is a POC Needed? • “In accordance with Section 7317 of the State Operations Manual, the purpose of a post survey revisit is to re-evaluate the specific care and services that were cited as noncompliant during the original survey.”

5. The SA reviews the POC for: • Appropriateness • Legibility • Completeness

6. What must a POC have to be complete? • Entered on the right side of Form 2567 opposite the deficiency • Include a planned action to correct the deficiency • Realistic date when the deficiency is corrected • Signed and dated by the administrator

7. An acceptable POC must: • “Address what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.”

8. An acceptable POC must: • “Address how the facility will identify other residents having the potential to be affected by the same deficient practice.”

9. An acceptable POC must: • “Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.”

10. Examples of Measures/Systemic Changes could be: • Policy Revision • Procedure (new or revised) • Monitor and Interface with QA Studies • Specific In-Service • New Staff Orientation & regular staff in-service schedules

11. Example: • “When new lab work is ordered, the charge nurse on each unit will take off the order, enter it in the log book and contact the lab rep.” • “An in-service on lab protocol was provided to all nurses on 3/14/07 by the DON. This in-service is now part of new hire orientation and during annual staff development training.”

12. An acceptable POC must: • “Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved & sustained. This plan must be implemented & the corrective action evaluated for its effectiveness. The POC is integrated in the QA system.”

13. Example: • “Weekly the DON, ADON, or Unit Supervisors, will review 5 charts on each unit to determine who took the orders off, check the lab log for a corresponding entry, determine if lab has been contacted. Don will interview nurses with emphasis on new hires to determine protocol understanding. This documentation will be kept in the DON’s office.

14. An acceptable POC must: • “Include dates when corrective action will be completed.” • The corrective action completion dates must be acceptable to the State.

15. Review of components for POC: • Address how corrective action will take place for those residents affected by the deficient practice. • Address how the facility will identify other residents having the potential to be affected by the deficient practice.

16. Continued Review: • Address what measures will be put into place or systemic changes so the deficient practice will not recur. • Indicate how the facility plans to monitor its performance. • Include dates when corrective action will be completed.

17. Remember… • The facility is ultimately accountable for their own action compliance. • It is important to have a clear and concise POC that covers: 1. Who is responsible for completing the action & documentation 2. Timeline for the action is be accomplished 3. How the action is to be monitored