ELEMENTS OF A PLAN OF ELEMENTS OF A PLAN OF CORRECTION AND PAST NON-CORRECTION AND PAST NON-

COMPLIANCECOMPLIANCE

STATE OF MICHIGANSTATE OF MICHIGANDEPARTMENT OF COMMUNITY HEALTHDEPARTMENT OF COMMUNITY HEALTH

BUREAU OF HEALTH SYSTEMSBUREAU OF HEALTH SYSTEMS

WELCOMEWELCOME

PRESENTERS:PRESENTERS:

ALICE B. TURNER, DIVISION DIRECTORALICE B. TURNER, DIVISION DIRECTOR NURSING HOME MONITORING DIVISIONNURSING HOME MONITORING DIVISION

KAREN J. ANTHONY, ASSISTANT DIVISION KAREN J. ANTHONY, ASSISTANT DIVISION DIRECTORDIRECTOR

NURSING HOME MONITORING DIVISIONNURSING HOME MONITORING DIVISION

OBJECTIVES:OBJECTIVES:

HOW TO WRITE A PLAN OF CORRECTION HOW TO WRITE A PLAN OF CORRECTION (PoC)(PoC)

Content of the PoCContent of the PoC Resident-Centered DeficienciesResident-Centered Deficiencies Facility-Centered DeficienciesFacility-Centered Deficiencies PoC Completion DatesPoC Completion Dates Disputing DeficienciesDisputing Deficiencies PoC as Allegation of CompliancePoC as Allegation of Compliance Attachments to PoCAttachments to PoC Questions Regarding the PoC ProcessQuestions Regarding the PoC Process Compliance Date DeterminationCompliance Date Determination Examples of Information NOT Applicable to the PoCExamples of Information NOT Applicable to the PoC

HOW TO WRITE A PoCHOW TO WRITE A PoC

Why a Plan of Correction?Why a Plan of Correction?

To encourage facilities to correct deficiencies asTo encourage facilities to correct deficiencies as

soon as possible.soon as possible. Commitment to correct each deficiency by a Commitment to correct each deficiency by a

specific completion date.specific completion date. Submission of an acceptable PoC is required forSubmission of an acceptable PoC is required for

all deficiencies of scope and severity Levels Ball deficiencies of scope and severity Levels B

through L.through L.

Fax copies of PoCs are not Fax copies of PoCs are not approved. Why?approved. Why?

The quality of faxed copies varyThe quality of faxed copies vary

Original document must be sent to Original document must be sent to the correct address as identified in the correct address as identified in the cover letter.the cover letter.

Plan of Correction (PoC)Plan of Correction (PoC)

A PoC for the deficiencies must be submitted within 10 calendar days from the receipt A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to of CMS-2567 report to Antoinette Ellis, Licensing Officer, Bureau of Health Antoinette Ellis, Licensing Officer, Bureau of Health Systems, MDCH, (mailing address) P.O. Box 02981, Detroit, Michigan 48202 Systems, MDCH, (mailing address) P.O. Box 02981, Detroit, Michigan 48202 or (street address) Cadillac Place, Suite 11-150, 3026 W. Grand Blvd., or (street address) Cadillac Place, Suite 11-150, 3026 W. Grand Blvd., Detroit, Michigan 48202.Detroit, Michigan 48202. Failure to submit an acceptable POC by Failure to submit an acceptable POC by April 4, 2009April 4, 2009 may result in immediate imposition of Category 1 enforcement remedies (State may result in immediate imposition of Category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions.enforcement actions.

A PoC for the deficiencies must be submitted within 10 calendar days from the receipt A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to of CMS-2567 report to Catherine Hunter, Licensing Officer, Bureau of Health Catherine Hunter, Licensing Officer, Bureau of Health Systems, MDCH, (street address) Alpine Executive Center, S-108, 400 W. Systems, MDCH, (street address) Alpine Executive Center, S-108, 400 W. Main Street, Gaylord, Michigan 49735. Main Street, Gaylord, Michigan 49735. Failure to submit an acceptable PoC by Failure to submit an acceptable PoC by June 28, 2009June 28, 2009 may result in immediate imposition of category 1 enforcement may result in immediate imposition of category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions.Training) or other enforcement actions.

A PoC for the deficiencies must be submitted within 10 calendar days from the receipt A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to of CMS-2567 report to Timothy D. Smith, Licensing Officer, Bureau of Health Timothy D. Smith, Licensing Officer, Bureau of Health Systems, MDCH, (street address) 1808 W. Saginaw Street, Lansing, Michigan Systems, MDCH, (street address) 1808 W. Saginaw Street, Lansing, Michigan 48915.48915. Failure to submit an acceptable PoC by Failure to submit an acceptable PoC by February 15, 2009February 15, 2009 may result in may result in immediate imposition of category 1 enforcement remedies (State Monitoring, Directed immediate imposition of category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions.Plan of Correction and/or Directed Inservice Training) or other enforcement actions.

Content of the PoCContent of the PoC

Resident or staff identifiers used by MDCH in the Resident or staff identifiers used by MDCH in the statement of deficiencies may be used in the PoC.statement of deficiencies may be used in the PoC.

Facility should do an in-depth analysis to Facility should do an in-depth analysis to ascertain why the problem exists and occurred so ascertain why the problem exists and occurred so as to develop solutions necessary to achieve as to develop solutions necessary to achieve resolution and sustain compliance.resolution and sustain compliance.

The required content of the PoC for each The required content of the PoC for each deficiency depends upon whether the deficiency deficiency depends upon whether the deficiency is is resident-centered resident-centered or or facility-centered.facility-centered.

Resident-Centered DeficienciesResident-Centered Deficiencies

Are violations of requirements thatAre violations of requirements that

must be met for each resident.must be met for each resident.

EXAMPLES EXAMPLES of such deficiencies of such deficiencies include failure to:include failure to:

Prevent pressure soresPrevent pressure sores

Protect the dignity of residentsProtect the dignity of residents

Provide notice prior to transferProvide notice prior to transfer

Adequately assess residentsAdequately assess residents

Element 1: Element 1: the PoC for resident-centered the PoC for resident-centered deficiencies should give a general deficiencies should give a general accounting of how the deficiencies cited accounting of how the deficiencies cited during the survey for a specific resident during the survey for a specific resident have been corrected. It should be noted have been corrected. It should be noted that the residents cited represent those that the residents cited represent those examples discovered from the resident examples discovered from the resident samples used in the survey.samples used in the survey.

Element 2: Element 2: must state how all other must state how all other residents who have been, or could be, residents who have been, or could be, affected by the generic deficient practice affected by the generic deficient practice have been identified.have been identified.

Element 3 and 4: Element 3 and 4: must demonstrate must demonstrate that the facility has considered all that the facility has considered all residents in their plan of development.residents in their plan of development.

Corrective measures facilities Corrective measures facilities should consider for Element 3 of should consider for Element 3 of

their PoC include, but are not their PoC include, but are not limited to:limited to:

In-service trainingIn-service training Off-site trainingOff-site training Information sharing with other facilitiesInformation sharing with other facilities Use of consultantsUse of consultants Interdisciplinary, multi-level quality improvement teamsInterdisciplinary, multi-level quality improvement teams Resident Council inputResident Council input Ombudsman inputOmbudsman input Physical environment enhancementsPhysical environment enhancements Expansion of staff numbers/qualificationsExpansion of staff numbers/qualifications Staff supervision and disciplineStaff supervision and discipline

Corrective measures facilities Corrective measures facilities should consider for Element 4 of should consider for Element 4 of

their PoC include, but are not their PoC include, but are not limited to:limited to:

Oversight by DON or other Oversight by DON or other management personnelmanagement personnel

Customer surveysCustomer surveys Resident Council feedbackResident Council feedback Ombudsman feedbackOmbudsman feedback Interviews with residents and familiesInterviews with residents and families

Facility-Centered DeficienciesFacility-Centered Deficiencies

In general, these are “system” In general, these are “system” deficiencies such as:deficiencies such as:

Lack of an infection control programLack of an infection control program

Inadequate staffingInadequate staffing

An inoperative fire alarm systemAn inoperative fire alarm system

Facility-Centered DeficienciesFacility-Centered Deficiencies

Element 1Element 1: How corrective action has been or will be accomplished : How corrective action has been or will be accomplished for the facility-centered deficient practice;for the facility-centered deficient practice;

Element 2Element 2: What measures have been or will be put into place or : What measures have been or will be put into place or systemic changes made to ensure that the deficient practice will not systemic changes made to ensure that the deficient practice will not recur; andrecur; and

Element 3Element 3: How the facility will monitor its corrective actions to : How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not ensure that the deficient practice is being corrected and will not recur; i.e.; what quality assurance program will be put into place.recur; i.e.; what quality assurance program will be put into place.

Note: Some regulatory requirements (Example: F-248) deal with Note: Some regulatory requirements (Example: F-248) deal with both individual residents both individual residents ANDAND facility systems. For deficiencies that facility systems. For deficiencies that have both facets, be sure to address each facet in the corrective have both facets, be sure to address each facet in the corrective response.response.

PoC Completion DatesPoC Completion Dates

A A singlesingle date of completion (month, day, date of completion (month, day, year) must be entered in the right-hand year) must be entered in the right-hand column of the CMS-2567 or State report for column of the CMS-2567 or State report for each each deficiency.deficiency.

Only Only oneone PoC date is allowed for each PoC date is allowed for each deficiency.deficiency.

The earliest allowable correction date is The earliest allowable correction date is one one day after the survey completion dateday after the survey completion date shown at the top of the report.shown at the top of the report.

Disputing DeficienciesDisputing Deficiencies Level 1: Level 1: Before surveyors leave the facility, Before surveyors leave the facility, notnot after you after you

receive 2567.receive 2567.

Level 2: Level 2: Please refer to the MDCH Informal Deficiency Dispute Please refer to the MDCH Informal Deficiency Dispute Resolution for LTC Facilities document for the process of Resolution for LTC Facilities document for the process of submitting Level 2 requests for IDR review of deficiencies. If a submitting Level 2 requests for IDR review of deficiencies. If a Level 2 request is submitted for a deficiency, the facility may Level 2 request is submitted for a deficiency, the facility may acknowledge its submission by placing the following statement acknowledge its submission by placing the following statement at the beginning at the beginning of the PoC for each deficiency in question. of the PoC for each deficiency in question.

““The facility objects to this deficiency and has invoked The facility objects to this deficiency and has invoked its’ right to utilize the Informal Deficiency Dispute its’ right to utilize the Informal Deficiency Dispute Resolution process for Tag ____”. (See page 10 of the Resolution process for Tag ____”. (See page 10 of the Guidelines.)Guidelines.)

You may request the IDR be reviewed by either the You may request the IDR be reviewed by either the Bureau of Health Systems or MPRO.Bureau of Health Systems or MPRO.

INFORMAL DEFICIENCY REVIEW INFORMAL DEFICIENCY REVIEW REQUEST – LEVEL 2 HANDOUTREQUEST – LEVEL 2 HANDOUT

PoC used as an Allegation of PoC used as an Allegation of ComplianceCompliance

The PoC is automatically considered The PoC is automatically considered to be the facility’s allegation of to be the facility’s allegation of compliance as of the latest PoC compliance as of the latest PoC correction date given in the PoCcorrection date given in the PoC

If you use several dates, the latest If you use several dates, the latest date is automatically useddate is automatically used

Attachments to the PoCAttachments to the PoC

Restrict PoC attachments to those Restrict PoC attachments to those documents that are necessary to documents that are necessary to support the specific contents contained support the specific contents contained with the Pocwith the Poc

Extraneous materials are of no value Extraneous materials are of no value and may result in unnecessary delays and may result in unnecessary delays to the processto the process

REVISITSREVISITS

Revisits may be conducted at any time Revisits may be conducted at any time for any level of non-compliance.for any level of non-compliance.

Revisits are required for:Revisits are required for:

1) Non-Compliance at F (Substandard 1) Non-Compliance at F (Substandard Quality of Care)Quality of Care)

2) Harm level citations2) Harm level citations

3) Immediate Jeopardy3) Immediate Jeopardy

QuestionsQuestionsRegarding the PoC ProcessRegarding the PoC Process

Facility questions regarding all aspects ofFacility questions regarding all aspects of the PoC process may be directed to the the PoC process may be directed to the Licensing Officer:Licensing Officer:

Detroit Office – Antoinette EllisDetroit Office – Antoinette Ellis Gaylord Office – Catherine HunterGaylord Office – Catherine Hunter Lansing Officer – Timothy SmithLansing Officer – Timothy Smith

Questions related to the Complaint PoC should be Questions related to the Complaint PoC should be directed to the Manager of the Complaint directed to the Manager of the Complaint Investigation Unit – John Rojeski Investigation Unit – John Rojeski

Compliance Date DeterminationCompliance Date Determination

The revisit date is the compliance date The revisit date is the compliance date (when correction is verified), except (when correction is verified), except when:when:

The revisit determines The revisit determines allall deficiencies have deficiencies have been corrected, andbeen corrected, and

The facility is in substantial compliance, The facility is in substantial compliance, andand The facility provides acceptable evidence to The facility provides acceptable evidence to

establish a correction prior to the first or establish a correction prior to the first or second revisit datesecond revisit date

Compliance Date Determination Compliance Date Determination (cont.)(cont.)

11stst Revisit: Revisit:

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

Compliance Date Determination Compliance Date Determination (cont.)(cont.)

22ndnd Revisit: Revisit: CMS allows a date earlier than the CMS allows a date earlier than the exit, if the citation does not require observations. exit, if the citation does not require observations. If observations are needed and verification of an If observations are needed and verification of an earlier compliance cannot be determined the exit earlier compliance cannot be determined the exit date will be used.date will be used.

33rdrd or 4 or 4thth Revisit: Revisit: Compliance (when correction Compliance (when correction is verified) is certified as of the date of the 3is verified) is certified as of the date of the 3rdrd or or 44thth revisit. CMS does not allow a compliance date revisit. CMS does not allow a compliance date earlier than the revisit date for the third or earlier than the revisit date for the third or subsequent revisits. subsequent revisits.

Life Safety Code (LSC) revisits does not count Life Safety Code (LSC) revisits does not count toward the Health Survey.toward the Health Survey.

Compliance Date Determination Compliance Date Determination (cont.)(cont.)

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

Evidence in Lieu of RevisitEvidence in Lieu of Revisit

In some cases, acceptable level of In some cases, acceptable level of compliance may be submitted in lieu compliance may be submitted in lieu of a revisit.of a revisit.

Evidence of compliance in lieu of Evidence of compliance in lieu of revisit is not acceptable after a revisit is not acceptable after a second revisit has been conducted.second revisit has been conducted.

Evidence in Lieu of RevisitEvidence in Lieu of Revisit

Examples of acceptable evidence are:Examples of acceptable evidence are:

1) Invoice or receipt verifying repairs, 1) Invoice or receipt verifying repairs, purchases, etc.purchases, etc.

2) Sign-in sheets for in-service training 2) Sign-in sheets for in-service training verifying attendanceverifying attendance

3) Contact with resident council3) Contact with resident council

FACILITY REQUEST TO ACCEPT FACILITY REQUEST TO ACCEPT EVIDENCE OF DEFICIENCY EVIDENCE OF DEFICIENCY CORRECTION IN LIEU OF A CORRECTION IN LIEU OF A

REVISIT HANDOUTREVISIT HANDOUT

ELEMENTS OF PAST NON-ELEMENTS OF PAST NON-COMPLIANCECOMPLIANCE

Criteria for Past Non-ComplianceCriteria for Past Non-Compliance

To cite past non-compliance, all three To cite past non-compliance, all three (3) criteria must be met:(3) criteria must be met:

1. The facility must not have been in 1. The facility must not have been in compliance with a regulatory compliance with a regulatory requirementrequirement at the time the situation at the time the situation occurred, i.e. the facility must have occurred, i.e. the facility must have had a violation; andhad a violation; and

Criteria for Past Non-Compliance Criteria for Past Non-Compliance cont.cont.

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

Criteria for Past Non-Compliance Criteria for Past Non-Compliance cont.cont.

3. There must be3. There must be specific evidencespecific evidence that the facility correctedthat the facility corrected the non-the non-compliance (at the time of the compliance (at the time of the incident) and is in substantial incident) and is in substantial compliance at the current survey.compliance at the current survey.

Documentation of Past Non-Documentation of Past Non-ComplianceCompliance

1. Past non-compliance1. Past non-compliance that is not that is not Immediate Jeopardy andImmediate Jeopardy and for which a for which a quality assurance program has corrected quality assurance program has corrected the non-compliance, should not be cited.the non-compliance, should not be cited. Note: The facility needs to bring this Note: The facility needs to bring this to the attention of the surveyor. to the attention of the surveyor. The The facility must provide the evidence to the facility must provide the evidence to the surveyor who will contact his/her manager surveyor who will contact his/her manager to review the information and make a to review the information and make a determination if the evidence meets the determination if the evidence meets the criteria for past non-compliance.criteria for past non-compliance.

FACILITY PAST NON-COMPLIANCE FACILITY PAST NON-COMPLIANCE CHECKLIST HANDOUTCHECKLIST HANDOUT

Documentation of Past Non-Documentation of Past Non-Compliance cont.Compliance cont.

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

Documentation of Past Non-Documentation of Past Non-Compliance cont.Compliance cont.

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

Documentation of Past Non-Documentation of Past Non-Compliance cont.Compliance cont.

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

Facility Past Non-Compliance Facility Past Non-Compliance ChecklistChecklist

(This is a tool, not a required document.)(This is a tool, not a required document.) Description of deficient practice: (Why and how did it happen?)Description of deficient practice: (Why and how did it happen?)

Plan of Correction:Plan of Correction: In-depth analysis of how the deficiency occurred.In-depth analysis of how the deficiency occurred. How facility identified resident affected and residents having How facility identified resident affected and residents having

potential to be affected by the same deficient practice.potential to be affected by the same deficient practice. Corrective action taken for resident affectedCorrective action taken for resident affected Measures or systemic changes made to ensure that deficient Measures or systemic changes made to ensure that deficient

practice will not recur and affect others.practice will not recur and affect others. How facility monitors its corrective actions to ensure deficient How facility monitors its corrective actions to ensure deficient

practice is corrected and will not recur.practice is corrected and will not recur.

Date of completion of plan of correction. Attach documents for Date of completion of plan of correction. Attach documents for evidence of compliance.evidence of compliance.

Name (printed) and Signature of person completing formName (printed) and Signature of person completing form

Enforcement Related to Past-Enforcement Related to Past-Non ComplianceNon Compliance

NOTE: Enforcement Action on NOTE: Enforcement Action on Immediate Jeopardy Past Non-Immediate Jeopardy Past Non-ComplianceCompliance

1.1. Civil money penalty is required for Civil money penalty is required for immediate jeopardy. Usually a per immediate jeopardy. Usually a per instance instance CMPCMP is imposed. is imposed.

2.2. NOTE: NOTE: Past non-compliance does not Past non-compliance does not apply to State Nursing Home Rules and apply to State Nursing Home Rules and the Public Health Code. A State of the Public Health Code. A State of Michigan-tag (M-tag) will be cited.Michigan-tag (M-tag) will be cited.

INFORMAL DEFICIENCY REVIEW INFORMAL DEFICIENCY REVIEW (IDR)(IDR)

IDRIDR

1. Will be allowed for past non-compliance 1. Will be allowed for past non-compliance cites.cites.

i.e., To contest whether a deficiency i.e., To contest whether a deficiency occurred.occurred.

2. 2. CanCan IDR whether a past non-compliance IDR whether a past non-compliance citation is a deficiency.citation is a deficiency.

3. 3. Cannot Cannot IDR whether a deficiency (cite) IDR whether a deficiency (cite) is past non-compliance.is past non-compliance.

QUESTIONS ?QUESTIONS ?

RESOURCESRESOURCES

Bureau of Health SystemsBureau of Health Systemshttp://http://www.michigan.gov/bhswww.michigan.gov/bhs

State Operations Manual (CMS)State Operations Manual (CMS)Appendix PAppendix P

http://cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdfhttp://cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf

Appendix PPAppendix PPhttp://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdfhttp://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf