You’ve been incredibly anxious about your upcoming triennial survey. You’ve done your best to prep for survey, but that little voice in the back of your head is telling you there’s something you missed.
The day finally comes when surveyors show up at your door. When all is said and done, you think you can finally let out a sigh of relief. But it turns out you have a few deficiencies. You get an email from your accreditor, who’s issued your agency a Plan of Correction (POC).
You understand it’s essential to your agency’s success to respond to the POC, but you may not know where to start. Is there a timeline you have to respond by? How do you actually respond to the POC? What do you have to communicate to your team to move things along efficiently and effectively? Are there fines you have to pay because of this, and how will it affect you financially?
The Home Health Consultant has years of experience helping agencies like yours respond effectively to POCs and stay compliant with federal, accreditor, and state standards.
By the end of this article, you’ll have a concrete grasp of:
- The different kinds of Plan of Corrections
- How to Respond to a Survey Deficiency with a Plan of Correction
- An Example of What Should be Included in a Plan of Correction
- How Your Accreditor Affects Your Plan of Correction
- What Home Health & Hospice Surveyors Want to See in a Plan of Correction
- Consequences of Not Submitting Your Plan of Correction on Time
- Next Steps & Resources If You Need Assistance Submitting a Plan of Correction
By preparing yourself with the right knowledge, you’ll feel ready to tackle any kind of survey and its results, regardless of receiving a POC or not.
What is a Plan of Correction (POC) in Home Health & Hospice?
A Plan of Correction (POC) is a document issued if a surveyor identifies deficiencies within your agency during a survey. This document details the specific issues discovered and provides space for your agency to respond with a plan to correct each deficiency. These deficiencies fall into two primary categories:
- Standard Deficiency: These are less severe and do not cause a survey failure. You typically have 30 days to address these.
- Conditional Deficiency: These are more serious issues that may result in survey failure. They require a response within 10 days, and in many cases, a resurvey will follow within 45 days.
Plans of correction address both standard and conditional deficiencies, with the level of severity impacting the time and detail required in your response.
Types of Survey Deficiencies and the Timeline for POC Response
The response timeline varies depending on the severity of deficiency. For example:
- Standard Deficiencies allow 30 days for a plan of correction submission.
- CoP Conditional Deficiencies require response within 10 days due to a stricter 45-day window for resolution and potential resurvey. The urgency stems from the need to correct severe issues quickly to maintain patient safety, and to allow time for a focus survey, if necessary
Typically, you should aim to submit your plan of correction within 10 business days of receiving a survey report, giving time for any regulatory checks needed.
How to Respond to a Plan of Correction
Once notified of a deficiency, your response should follow a clear structure:
- Identify the Root Cause: Determine why the deficiency occurred. For example, if a deficiency is found in patient chart documentation, investigate whether the issue is due to inadequate training, lack of resources, or other procedural gaps. Including this root cause demonstrates to surveyors that your agency has taken steps to understand and address the underlying issue.
- Describe Corrective Actions: Outline the specific actions taken to address the deficiency. This may include retraining staff, conducting chart audits, or updating policies. The key is to specify actions already completed to show the governing agency that immediate steps have been taken.
- Include a Date of Compliance: Clearly state the date by which the deficiency has been resolved. Your date of compliance is not the day you expect to have deficiencies resolved, it’s the day you’ve finished making the correction(s).
- Describe Methods to Prevent Recurrence: Explain what processes you have added or changed to ensure the deficiency doesn’t happen again. Be specific when it comes to the numbers. How many charts will you audit and how often? What is an acceptable pass rate for this issue? Make sure these monitoring activities occur regularly. For example, they could be part of monthly chart audits or annual competencies to ensure lasting change.
- Assign Responsibility: Designate a person responsible for overseeing the corrective measures. For example, an administrator may handle operational issues, while a clinical issue might fall to the Director of Patient Care Services (DPCS). This establishes accountability and ensures governing agencies know who to contact for updates.
Example of What Should Be Included in a Plan of Correction
Let’s consider an example. Suppose a survey identifies that your agency hasn’t reconciled medications on time:
- Root Cause: Staff may be unclear on the frequency required for medication reconciliation.
- Corrective Action: Staff have been retrained on the reconciliation schedule. An initial audit of all active patient charts has been completed to identify any non-compliance. Clinicians have completed a medication reconciliation at their next visit for any records identified as being non-compliant.
- Date of Compliance: Set within the standard 30-day or conditional 10-day period.
-Recurrence Prevention: A line is added to chart audit forms to ensure clinicians and staff practice proper medication reconciliation frequency.
- Responsible Person: Administrator or DPCS, as appropriate.
The example above does a great job at addressing the compliance issue by following the steps outlined in this article. However, it could be improved by including measurable outcomes and additional follow-up steps to ensure ongoing compliance.
How Your Accreditor Affects Your Plan of Correction
Different accrediting bodies may have slightly varying expectations for POC submissions. For example:
- California State Surveys might require extensive, multi-page responses for each deficiency, often leading to back-and-forth requests for additional details.
- ACHC & CHAP may accept brief, focused responses.
- TJC generally demands high detail, especially for conditional deficiencies, expecting data-backed submissions like chart audit results or other documentation.
Non-government accrediting bodies often take an educational approach, providing guidance during surveys. However, government accrediting bodies tend to be more stringent and less focused on education.
What Surveyors Want to See in a Plan of Correction
To improve the chances of your POC’s approval:
- Provide Detail: Describe the full process related to the deficiency, showing surveyors how your agency’s correction fits into your broader practices.
- Educate Staff Thoroughly: When training staff on corrective actions, include not just the specific deficiency but also related regulatory expectations.
- Be Proactive and Timely: Submit the POC as quickly as possible, especially for conditional deficiencies, as accrediting bodies may request additional information.
Consequences of Not Submitting a POC on Time
Failure to submit a POC, especially for conditional deficiencies, can have severe repercussions. Delays or incomplete submissions can result in additional penalties, potential fines, and in extreme cases, provider termination. Accrediting bodies may grant minor extensions, but these are limited to hours or, at most, a day.
Guidance and Resources to Master Your Plan of Correction
For agency owners and administrators, a plan of correction can be overwhelming. Consulting services can provide guidance and templates to streamline the response process. Experienced consultants can assist with drafting POCs, conducting staff education, and ensuring a comprehensive and compliant response.
Receiving a POC might feel daunting, but by understanding the process and following structured steps, your agency can respond confidently. Proper preparation ensures compliance, reduces risks, and ultimately contributes to better patient care. Remember, when in doubt, leverage the educational resources provided by accrediting bodies or consider consulting support to navigate the process smoothly.
If you’re still feeling uncertain about tackling your plan of correction, don’t hesitate to take the next step. Download our free guide with tips on how to make sure your plan of correction is in good shape before you submit.
If you're looking for extra support with surveys, maintaining compliance, and more, check out our article below for the most common timepoints in an agency's lifecycle that they hire consultants.
*This article was written in consultation with Mariam Treystman.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
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