ELEMENTS OF A PLAN OF CORRECTION AND PAST NON-COMPLIANCE

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ELEMENTS OF A PLAN OF CORRECTION AND PAST
NON-COMPLIANCE

• STATE OF MICHIGAN
• DEPARTMENT OF COMMUNITY HEALTH
• BUREAU OF HEALTH SYSTEMS

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• WELCOME

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PRESENTERS

• ALICE B. TURNER, DIVISION DIRECTOR
• NURSING HOME MONITORING DIVISION
• KAREN J. ANTHONY, ASSISTANT DIVISION DIRECTOR
• NURSING HOME MONITORING DIVISION

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OBJECTIVES

• HOW TO WRITE A PLAN OF CORRECTION (PoC)
• Content of the PoC
• Resident-Centered Deficiencies
• Facility-Centered Deficiencies
• PoC Completion Dates
• Disputing Deficiencies
• PoC as Allegation of Compliance
• Attachments to PoC
• Questions Regarding the PoC Process
• Compliance Date Determination
• Examples of Information NOT Applicable to the
  PoC

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HOW TO WRITE A PoC

• Why a Plan of Correction?
• To encourage facilities to correct deficiencies
  as
• soon as possible.
• Commitment to correct each deficiency by a
• specific completion date.
• Submission of an acceptable PoC is required for
• all deficiencies of scope and severity
  Levels B
• through L.

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Fax copies of PoCs are not approved. Why?

• The quality of faxed copies vary
• Original document must be sent to the correct
  address as identified in the cover letter.

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• Plan of Correction (PoC)
• A PoC for the deficiencies must be submitted
  within 10 calendar days from the receipt of
  CMS-2567 report to Antoinette Ellis, Licensing
  Officer, Bureau of Health Systems, MDCH, (mailing
  address) P.O. Box 02981, Detroit, Michigan 48202
  or (street address) Cadillac Place, Suite 11-150,
  3026 W. Grand Blvd., Detroit, Michigan 48202.
  Failure to submit an acceptable POC by April 4,
  2009 may result in immediate imposition of
  Category 1 enforcement remedies (State
  Monitoring, Directed Plan of Correction and/or
  Directed Inservice Training) or other enforcement
  actions.
• A PoC for the deficiencies must be submitted
  within 10 calendar days from the receipt of
  CMS-2567 report to Catherine Hunter, Licensing
  Officer, Bureau of Health Systems, MDCH, (street
  address) Alpine Executive Center, S-108, 400 W.
  Main Street, Gaylord, Michigan 49735. Failure
  to submit an acceptable PoC by June 28, 2009 may
  result in immediate imposition of category 1
  enforcement remedies (State Monitoring, Directed
  Plan of Correction and/or Directed Inservice
  Training) or other enforcement actions.
• A PoC for the deficiencies must be submitted
  within 10 calendar days from the receipt of
  CMS-2567 report to Timothy D. Smith, Licensing
  Officer, Bureau of Health Systems, MDCH, (street
  address) 1808 W. Saginaw Street, Lansing,
  Michigan 48915. Failure to submit an acceptable
  PoC by February 15, 2009 may result in immediate
  imposition of category 1 enforcement remedies
  (State Monitoring, Directed Plan of Correction
  and/or Directed Inservice Training) or other
  enforcement actions.

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Content of the PoC

• Resident or staff identifiers used by MDCH in the
  statement of deficiencies may be used in the PoC.
• Facility should do an in-depth analysis to
  ascertain why the problem exists and occurred so
  as to develop solutions necessary to achieve
  resolution and sustain compliance.
• The required content of the PoC for each
  deficiency depends upon whether the deficiency is
  resident-centered or facility-centered.

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Resident-Centered Deficiencies

• Are violations of requirements that
• must be met for each resident.

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EXAMPLES of such deficiencies include failure to

• Prevent pressure sores
• Protect the dignity of residents
• Provide notice prior to transfer
• Adequately assess residents

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• Element 1 the PoC for resident-centered
  deficiencies should give a general accounting of
  how the deficiencies cited during the survey for
  a specific resident have been corrected. It
  should be noted that the residents cited
  represent those examples discovered from the
  resident samples used in the survey.
• Element 2 must state how all other residents
  who have been, or could be, affected by the
  generic deficient practice have been identified.
• Element 3 and 4 must demonstrate that the
  facility has considered all residents in their
  plan of development.

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Corrective measures facilities should consider
for Element 3 of their PoC include, but are not
limited to

• In-service training
• Off-site training
• Information sharing with other facilities
• Use of consultants
• Interdisciplinary, multi-level quality
  improvement teams
• Resident Council input
• Ombudsman input
• Physical environment enhancements
• Expansion of staff numbers/qualifications
• Staff supervision and discipline

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Corrective measures facilities should consider
for Element 4 of their PoC include, but are not
limited to

• Oversight by DON or other management personnel
• Customer surveys
• Resident Council feedback
• Ombudsman feedback
• Interviews with residents and families

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Facility-Centered Deficiencies

• In general, these are system deficiencies such
  as
• Lack of an infection control program
• Inadequate staffing
• An inoperative fire alarm system

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Facility-Centered Deficiencies

• Element 1 How corrective action has been or
  will be accomplished for the facility-centered
  deficient practice
• Element 2 What measures have been or will be
  put into place or systemic changes made to ensure
  that the deficient practice will not recur and
• Element 3 How the facility will monitor its
  corrective actions to ensure that the deficient
  practice is being corrected and will not recur
  i.e. what quality assurance program will be put
  into place.
• Note Some regulatory requirements (Example
  F-248) deal with both individual residents AND
  facility systems. For deficiencies that have
  both facets, be sure to address each facet in the
  corrective response.

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PoC Completion Dates

• A single date of completion (month, day, year)
  must be entered in the right-hand column of the
  CMS-2567 or State report for each deficiency.
• Only one PoC date is allowed for each deficiency.
• The earliest allowable correction date is one day
  after the survey completion date shown at the top
  of the report.

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Disputing Deficiencies

• Level 1 Before surveyors leave the facility,
  not after you receive 2567.
• Level 2 Please refer to the MDCH Informal
  Deficiency Dispute Resolution for LTC Facilities
  document for the process of submitting Level 2
  requests for IDR review of deficiencies. If a
  Level 2 request is submitted for a deficiency,
  the facility may acknowledge its submission by
  placing the following statement at the beginning
  of the PoC for each deficiency in question.
• The facility objects to this deficiency and has
  invoked its right to utilize the Informal
  Deficiency Dispute Resolution process for Tag
  ____. (See page 10 of the Guidelines.)
• You may request the IDR be reviewed by either the
  Bureau of Health Systems or MPRO.

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• INFORMAL DEFICIENCY REVIEW REQUEST LEVEL 2
  HANDOUT

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PoC used as an Allegation of Compliance

• The PoC is automatically considered to be the
  facilitys allegation of compliance as of the
  latest PoC correction date given in the PoC
• If you use several dates, the latest date is
  automatically used

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Attachments to the PoC

• Restrict PoC attachments to those documents that
  are necessary to support the specific contents
  contained with the Poc
• Extraneous materials are of no value and may
  result in unnecessary delays to the process

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REVISITS

• Revisits may be conducted at any time for any
  level of non-compliance.
• Revisits are required for
• 1) Non-Compliance at F (Substandard Quality
  of Care)
• 2) Harm level citations
• 3) Immediate Jeopardy

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QuestionsRegarding the PoC Process

• Facility questions regarding all aspects of
• the PoC process may be directed to the
• Licensing Officer
• Detroit Office Antoinette Ellis
• Gaylord Office Catherine Hunter
• Lansing Officer Timothy Smith
• Questions related to the Complaint PoC should be
  directed to the Manager of the Complaint
  Investigation Unit John Rojeski

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Compliance Date Determination

• The revisit date is the compliance date (when
  correction is verified), except when
• The revisit determines all deficiencies have been
  corrected, and
• The facility is in substantial compliance, and
• The facility provides acceptable evidence to
  establish a correction prior to the first or
  second revisit date

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Compliance Date Determination (cont.)

• 1st Revisit
• If the facility is in substantial compliance on
  the date of the first revisit, the compliance
  date is automatically the date accepted in the
  PoC, unless there is evidence that compliance was
  achieved on either an earlier or later date.

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Compliance Date Determination (cont.)

• 2nd Revisit CMS allows a date earlier than the
  exit, if the citation does not require
  observations. If observations are needed and
  verification of an earlier compliance cannot be
  determined the exit date will be used.
• 3rd or 4th Revisit Compliance (when correction
  is verified) is certified as of the date of the
  3rd or 4th revisit. CMS does not allow a
  compliance date earlier than the revisit date for
  the third or subsequent revisits.
• Life Safety Code (LSC) revisits does not count
  toward the Health Survey.

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Compliance Date Determination (cont.)

• Where more than one deficiency is involved, the
  latest correction date is used to determine
  compliance.

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Evidence in Lieu of Revisit

• In some cases, acceptable level of compliance may
  be submitted in lieu of a revisit.
• Evidence of compliance in lieu of revisit is not
  acceptable after a second revisit has been
  conducted.

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Evidence in Lieu of Revisit

• Examples of acceptable evidence are
• 1) Invoice or receipt verifying repairs,
  purchases, etc.
• 2) Sign-in sheets for in-service training
  verifying attendance
• 3) Contact with resident council

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• FACILITY REQUEST TO ACCEPT EVIDENCE OF DEFICIENCY
  CORRECTION IN LIEU OF A REVISIT HANDOUT

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• ELEMENTS OF PAST NON-COMPLIANCE

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Criteria for Past Non-Compliance

• To cite past non-compliance, all three (3)
  criteria must be met
• 1. The facility must not have been in compliance
  with a regulatory requirement at the time the
  situation occurred, i.e. the facility must have
  had a violation and

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Criteria for Past Non-Compliance cont.

• 2. The situation of non-compliance must have
  occurred after the exit date of the last survey,
  and before the current survey (standard,
  complaint, revisit) and

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Criteria for Past Non-Compliance cont.

• 3. There must be specific evidence that the
  facility corrected the non-compliance (at the
  time of the incident) and is in substantial
  compliance at the current survey.

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Documentation of Past Non-Compliance

• 1. Past non-compliance that is not Immediate
  Jeopardy and for which a quality assurance
  program has corrected the non-compliance, should
  not be cited. Note The facility needs to bring
  this to the attention of the surveyor. The
  facility must provide the evidence to the
  surveyor who will contact his/her manager to
  review the information and make a determination
  if the evidence meets the criteria for past
  non-compliance.

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• FACILITY PAST NON-COMPLIANCE CHECKLIST HANDOUT

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Documentation of Past Non-Compliance cont.

• 2. Past non-compliance identified as immediate
  jeopardy is entered on the CMS-2567 under the
  specific deficiency tag, scope and severity with
  supporting documentation.

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Documentation of Past Non-Compliance cont.

• 3. The CMS-2567 should include the appropriate
  F-tag, date of deficiency, the date of past
  non-compliance, the evidence of past
  non-compliance and implementation of a plan of
  correction so that the civil money penalty can be
  determined.

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Documentation of Past Non-Compliance cont.

• 4. No PoC is required for past non-compliance
  citations. No revisit is conducted for past
  non-compliance citations.

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Facility Past Non-Compliance Checklist

• (This is a tool, not a required document.)
• Description of deficient practice (Why and how
  did it happen?)
• Plan of Correction
• In-depth analysis of how the deficiency occurred.
• How facility identified resident affected and
  residents having potential to be affected by the
  same deficient practice.
• Corrective action taken for resident affected
• Measures or systemic changes made to ensure that
  deficient practice will not recur and affect
  others.
• How facility monitors its corrective actions to
  ensure deficient practice is corrected and will
  not recur.
• Date of completion of plan of correction. Attach
  documents for evidence of compliance.
• Name (printed) and Signature of person completing
  form

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Enforcement Related to Past-Non Compliance

• NOTE Enforcement Action on Immediate Jeopardy
  Past Non-Compliance
• Civil money penalty is required for immediate
  jeopardy. Usually a per instance CMP is imposed.
• NOTE Past non-compliance does not apply to
  State Nursing Home Rules and the Public Health
  Code. A State of Michigan-tag (M-tag) will be
  cited.

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INFORMAL DEFICIENCY REVIEW (IDR)

• IDR
• 1. Will be allowed for past non-compliance
  cites.
• i.e., To contest whether a deficiency
  occurred.
• 2. Can IDR whether a past non-compliance
  citation is a deficiency.
• 3. Cannot IDR whether a deficiency (cite) is
  past non-compliance.

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• QUESTIONS ?

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RESOURCES

• Bureau of Health Systems
• http//www.michigan.gov/bhs
• State Operations Manual (CMS)
• Appendix P
• http//cms.hhs.gov/manuals/Downloads/som107ap_p_lt
  cf.pdf
• Appendix PP
• http//cms.hhs.gov/manuals/Downloads/som107ap_pp_g
  uidelines_ltcf.pdf