Posted on January 17th, 2024

After completing a CMS survey, the first step is to pause and celebrate your team's hard work and dedication. Remember, your team's efforts are the cornerstone of the survey's success. If your facility has aced the survey with no citations, that's a remarkable achievement - congratulations are in order! However, if you find yourself among the many who need to draft a Plan of Correction, it's normal to feel overwhelmed, possibly encountering one of the five stages of grief.

Facing a list of citations can be daunting, but remember, developing a comprehensive Plan of Correction (POC) is essential for a successful follow-up with CMS. At SMK Medical, we understand the challenges healthcare executives (NHA, DON, RDO) often face in creating an effective POC. This guide is crafted to support and empower you in developing a POC that meets compliance standards and contributes to ongoing quality improvement in your facility.

🌟 🌟 🌟 Exclusive Offer: Along with this guide, we offer our readers FREE access to over 25 essential tools to assist in your POC development. These tools are designed to streamline your process and enhance your facility's compliance and quality improvement efforts.🌟 🌟 🌟

1. Fully Grasp the Deficiencies: Start by thoroughly understanding each deficiency noted on the CMS-2567 form. A clear grasp of these issues is the first step toward an effective correction plan. Use a highlighter, and highlight the resident number and the reason for the deficiencies. Take time to detail each deficiency 

2. Conduct Root Cause Analysis: Analyzing the root cause of each deficiency is crucial. This insight is critical to developing targeted and effective corrective actions. Use the five whys process or the fishbone method to help you conduct a root cause analysis. 

3. Specify Corrective Actions: Outline specific, actionable steps for each issue. Avoid general statements like all residents, or We will fix the problem as soon as possible; clarity and precision in corrective actions are vital to receiving an acceptable POC. 

4. Engage Relevant Staff. Involve staff members who work directly in the deficient areas. Their firsthand experience is invaluable in crafting practical and realistic solutions.

5. Set Clear Timelines: Establish realistic deadlines for each corrective action. Precise timelines demonstrate commitment and facilitate monitoring.

6. Focus on Training and Education: If deficiencies stem from knowledge gaps, prioritize staff training and education in your POC to ensure long-term compliance and improvement.

7. Implement Systemic Changes: Address broader systemic issues if they contribute to the deficiencies. This might involve policy changes or process enhancements.

8. Plan for Monitoring and Evaluation: Outline how you'll monitor the implementation of corrective actions and assess their effectiveness. Use specific metrics for evaluation. Try setting smart goals for each intervention that will be monitored. If you are unfamiliar with smart goals, view our blog on setting smart goals HERE. 

9. Maintain Rigorous Documentation. Keep detailed records of all corrective steps taken. This documentation is crucial for compliance verification in subsequent inspections. It is standard practice to keep 5-7 years of documentation related to the plan of correction. 

10. Regularly Review and Update the POC: Adopt a continuous improvement approach (QAPI) by regularly reviewing and updating your processes based on their effectiveness and evolving needs. View our recent QAPI blog HERE 

Conclusion: Crafting a robust Plan of Correction in response to CMS-2567 findings is not just a regulatory requirement; it's a crucial step toward ensuring quality care and safety in your healthcare facility. With these ten strategic tips, healthcare executives can confidently navigate the complexities of compliance. SMK Medical is committed to empowering healthcare professionals with the knowledge, tools, and expertise necessary to excel in these challenges.

Need expert guidance in developing your Plan of Correction, Quality Assurance, and Performance Improvement (QAPI) or preparing for your next survey? SMK Medical is here to help. We specialize in PDPM/MDS, from thorough auditing to comprehensive completion services.

Discover how we can support your facility's success. Visit us at SMKMED.COM or contact us at 313-314-8267. 

P.S. Take advantage of our valuable survey tools - subscribe to our email list today and gain immediate access HERE. Our toolbox has over 25 helpful tools for you and your LTC facility.