Plan of Correction

Upon completion of a CMS, accreditation and/or state survey, facilities receive a written report which details the results of the surveyors findings. This report highlights standards that may require more attention and any applicable deficiencies (noncompliance issues). Deficiencies are of varying levels, and the facility is required to respond with a plan of correction (POC) within a certain timeframe, according to a specific format.

Developing a plan of correction can be a daunting task. It requires knowledge and experience. ICCS works with facilities to develop the plan of correction and ensures that they are specific, realistic and complete.

What makes POCs so challenging? Here are just a few of the requirements:

  • Each deficiency requires a response within the POC. The steps that have been or will be taken to achieve compliance must be highlighted, as must the timeframe for completion.
  • General statements are not acceptable. The POC must identify the nature of the corrective action, what systematic changes will be made to ensure that the deficient practice will not recur and how the facility will monitor its corrective action to ensure that the deficient practice is corrected (e.g., what quality assurance program will be put into place).
  • The POC must identify the position of the staff person(s) who will be responsible to monitor correction and the quality assurance mechanisms.
  • The POC must identify the date of completion or the expected date of completion.
  • A deficiency may require several corrective actions in order to achieve compliance, with each action having different dates of completion.
  • Many deficiencies, especially those involving the provision of direct care, must be corrected within shorter time frames.

Contact ICCS to learn about how we can help your facility develop a plan of correction, and how we can help you reduce the likelihood of deficiencies through our other services, including survey preparation and infection control risk assessment.



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