Writing a Plan of Correction for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL 33607 800.275.6252 www.polaris-group.com
Writing a POC Limited Copyright: April 2014, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH60 - Developed by Polaris Group www.polaris-group.com Page 1 of 43
Writing a POC POST-TEST 1. Which of the following timelines are incorrect? a. 1 st revisit between last date on the POC and 60 th b. 2 nd revisit no later than 155 th -165 th day c. 3 rd 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 d. None of the above 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 2 of 43
Writing a POC POST-TEST - ANSWERS 1. Which of the following timelines are incorrect? a. 1 st revisit between last date on the POC and 60 th b. 2 nd revisit no later than 155 th -165 th day c. 3 rd 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 D C 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 d. None of the above 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 3 of 43
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 Will include dates for Civil Money Penalties (CMP) or Remedies 3 Time Lines 1 st revisit following a survey with noncompliance-between the last date on the plan of correction and the 60 th day. 2 nd visit following continuing non-compliance Generally no later than 155 th and 165 th day following initial survey date. 3 rd revisit following survey with noncompliance Regional office must approve. 4 FH60 - Developed by Polaris Group www.polaris-group.com Page 4 of 43
5 Remedy Categories Category 1 Least Severe Directed plan of correction Category 3 Most State Monitor Severe Directed in-service training Temporary Category 2 Moderately Severe Management Denial of payment of new admissions Immediate -Medicaid Termination Denial of payment for all Optional lcivil il Medicare/Medicaid imposed by CMS Money Penalty: Civil Money Penalty: $50--$3000 $3050- New for immediate jeopardy-up to $10,000/day $10,000/day 6 FH60 - Developed by Polaris Group www.polaris-group.com Page 5 of 43
Least Severe Remedies Directed POC 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 State approved person is required to oversight plan of correction 7 Moderately Severe Remedies Denial of Payment 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 6 of 43
Moderately Severe Remedies Denial of Payment continued: 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 ban Med Part A may be available at another SNF 9 Moderately Severe Remedies Civil Money Penalties 50-$3000 dollars per day/per instance Applies to deficiencies that are not Immediate Jeopardy 10 FH60 - Developed by Polaris Group www.polaris-group.com Page 7 of 43
Severe Remedies Temporary Management Oversights POC but also has right to hire, terminate, manage funds and change procedures Termination Relocation of residents Optional CMP $3050-$10,000 For Immediate Jeopardy 11 Self-Reported Noncompliance Self-Reported Noncompliance- Noncompliance 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 ypenalty by 50 percent when a facility self-reports and promptly corrects a deficiency for which a civil money penalty is imposed by CMS 12 FH60 - Developed by Polaris Group www.polaris-group.com Page 8 of 43
Additional Steps for Substandard Care Citations 1. Resident Behavior and Facility Practices F-tags 221-226 2. Quality of Life F-tags 240-258 3. Quality of Care F-tags 309-333 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 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, 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 9 of 43
Additional Steps for Substandard 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 notification Starts cycle of Poor Performing facility You can dispute Substandard Care S/S 15 Opportunity to Correct Mandatory criteria for having No Opportunity to 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 causing actual harm on first survey after re-entry into program IJ citations Noncompliance with Per Instance CMP 16 FH60 - Developed by Polaris Group www.polaris-group.com Page 10 of 43
CMS 2567 Provider has following three options 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 criteria 1. 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 11 of 43
Plan of Correction Plan of correction must meet four criteria 3. 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 corrective actions to 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. 19 Plan of Correction Plan of correction must also include: 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 any reason, the State will notify the facility in writing. 20 FH60 - Developed by Polaris Group www.polaris-group.com Page 12 of 43
Plan of Correction Facilities should be cautioned that they are ultimately 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. 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 and/or in compliance. The title of the person responsible. 22 FH60 - Developed by Polaris Group www.polaris-group.com Page 13 of 43
Plan of Correction Tips Indicate dates by which corrective action will be completed most within 60 days 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 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 14 of 43
Plan of Correction Consider a Generic Disclaimer This 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, 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 limit the providers capacity to render care. 26 FH60 - Developed by Polaris Group www.polaris-group.com Page 15 of 43
Plan of Correction Consider a Generic Disclaimer 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 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 remain free of accident hazards as is possible. 28 FH60 - Developed by Polaris Group www.polaris-group.com Page 16 of 43
Plan of Correction 1. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice Address each Resident by number. State what was done and completion date. Completion date is usually already passed. 29 Plan of Correction 2. How the facility will identify other residents 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 residents with current pressure r ulcers will be reviewed. All resident on antipsychotics.. All residents inability to communicate needs 30 FH60 - Developed by Polaris Group www.polaris-group.com Page 17 of 43
Plan of Correction 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. May include: P&P review and revisions as needed. Inservice in general Training or counseling/firing g Change in process or procedures e.g. Review at daily stand-up Only list changes that you are really willing to implement 31 Plan of Correction 4. How the facility will monitor its corrective actions to 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 18 of 43
Presentation of Evidence Several methods are available: 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 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 immediately Attempt to remove before exit Requires onsite confirmation to remove Submit allegations of removal for re-visit 34 FH60 - Developed by Polaris Group www.polaris-group.com Page 19 of 43
Removal of Immediate Jeopardy Sufficient information to show: How 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 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 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 20 of 43
IDR May IDR a deficiency from a Revisit Survey if the 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 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. 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 21 of 43
Independent Informal Dispute Resolution (IIDR) IIDR may not be used to challenge: 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 Independent Informal Dispute Resolution (IIDR) 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 comments. FINAL DECISION- made by State. 40 FH60 - Developed by Polaris Group www.polaris-group.com Page 22 of 43
Appeal Process Consult with legal counsel File 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 disputing Specific deficiency i being disputed d 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 FH60 - Developed by Polaris Group www.polaris-group.com Page 23 of 43
SCOPE AND SEVERITY GRID IMMEDIATE JEOPARDY To Resident Health or Safety ACTUAL HARM That is not Immediate Jeopardy NO ACTUAL HARM with POTENTIAL FOR MORE THAN MINIMAL HARM that is not immediate jeopardy PoC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2 Substandard Quality of Care J PoC Required: Cat. 2 Optional: Cat. 1 PoC Required: Cat. 1 Optional: Cat. 2 G PoC Required: Cat. 3 Optional: Cat. 1 Optional: Cat. 2 Substandard Quality of Care K PoC Required: Cat. 2 Optional: Cat. 1 Substandard Quality of Care H PoC Required: Cat. 1 Optional: Cat. 2 PoC Required: Cat. 3 Optional: Cat. 2 Optional: Cat. 1 Substandard Quality of Care L PoC Required: Cat. 2 Optional: Cat. 1 Optional: Temp. Mgmt. Substandard Quality of Care I PoC Required: Cat. 2 Optional: Cat. 1 NO ACTUAL HARM with POTENTIAL FOR MINIMAL HARM No Plan of Correction No Remedies Commitment to Correct Not on CMS-2567 D A PoC E B Substandard Quality of Care F PoC C Substandard Care if F221-225, F240-258, F309-333 ISOLATED PATTERN WIDESPREAD Remedy Category 1 Directed Plan of Correction: State Monitor: And/or Directed In-service Training Remedy Category 2 Denial of Payment for New Admissions: Denial of Payment for All Individuals: Imposed by CMS And/or Civil Money Penalties $50-$3,000/day Remedy Category 3 Temporary Management: Termination Optional: Civil Money Penalties $3,050-$10,000/day FH60 - Developed by Polaris Group www.polaris-group.com Page 24 of 43
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