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ELEMENTS OF A PLAN OF CORRECTION AND PAST NON-COMPLIANCE

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Title: ELEMENTS OF A PLAN OF CORRECTION AND PAST NON-COMPLIANCE


1
ELEMENTS OF A PLAN OF CORRECTION AND PAST
NON-COMPLIANCE
  • STATE OF MICHIGAN
  • DEPARTMENT OF COMMUNITY HEALTH
  • BUREAU OF HEALTH SYSTEMS

2
  • WELCOME

3
PRESENTERS
  • ALICE B. TURNER, DIVISION DIRECTOR
  • NURSING HOME MONITORING DIVISION
  • KAREN J. ANTHONY, ASSISTANT DIVISION DIRECTOR
  • NURSING HOME MONITORING DIVISION

4
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

5
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.

6
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.

7
  • 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.

8
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.

9
Resident-Centered Deficiencies
  • Are violations of requirements that
  • must be met for each resident.

10
EXAMPLES of such deficiencies include failure to
  • Prevent pressure sores
  • Protect the dignity of residents
  • Provide notice prior to transfer
  • Adequately assess residents

11
  • 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.

12
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

13
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

14
Facility-Centered Deficiencies
  • In general, these are system deficiencies such
    as
  • Lack of an infection control program
  • Inadequate staffing
  • An inoperative fire alarm system

15
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.

16
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.

17
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.

18
  • INFORMAL DEFICIENCY REVIEW REQUEST LEVEL 2
    HANDOUT

19
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

20
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

21
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

22
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

23
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

24
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.

25
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.

26
Compliance Date Determination (cont.)
  • Where more than one deficiency is involved, the
    latest correction date is used to determine
    compliance.

27
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.

28
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

29
  • FACILITY REQUEST TO ACCEPT EVIDENCE OF DEFICIENCY
    CORRECTION IN LIEU OF A REVISIT HANDOUT

30
  • ELEMENTS OF PAST NON-COMPLIANCE

31
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

32
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

33
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.

34
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.

35
  • FACILITY PAST NON-COMPLIANCE CHECKLIST HANDOUT

36
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.

37
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.

38
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.

39
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

40
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.

41
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.

42
  • QUESTIONS ?

43
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
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