The Importance of a “Plan of Correction Attitude”
Wednesday, November 21, 2018
As an Administrator, do you address concerns in your facility with a “plan of correction attitude” even though you are not in survey, thus, not at risk of being cited? Could you show documented proof of your corrective actions to issues resolved in your facility? When a surveyor brings an issue to your attention, can you walk them through your facility’s identification of the issue, corrective actions taken, means to ensure ongoing compliance, and quality assurance measures implemented to confirm continued compliance? If so, the deficient practice could meet the definition of “past non-compliance.”
Past noncompliance may be cited on health and/or life safety code surveys. It may be cited on any type of survey (standard, recertification, abbreviated standard, e.g., complaint and revisit).
According to the State Operations Manual, Chapter7, Section 7510.1, “To cite past noncompliance with a specific survey data tag (F-tag or K-tag), all of the following three criteria must be met:
- The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific F-tag or K-tag) at the time the situation occurred;
- The noncompliance occurred after the exit date of the last standard (recertification) survey and before the survey (standard, complaint, or revisit) currently being conducted; and
- There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific F-tag or K-tag.”
In short, the facility must take credit for having identified the issue and for having corrected the issue which is now being identified by the surveyor, but occurred at some point in the past. If the facility can successfully exhibit its efforts (i.e., have “sufficient evidence”), the nursing facility is not required to provide a plan of correction for the deficiency cited as past noncompliance. Additionally, should there be an associated civil money penalty, it can be a per day or a per instance penalty. By limiting the timeframe of the noncompliance via sufficient evidence of the facility’s corrective actions, a daily fine from the time of survey and continuing until post survey revisit could possibly be reduced to only those days until the corrective actions were completed and deemed successful per substantial compliance thereafter. Per Chapter 7, “when it is difficult to accurately establish when the past noncompliance occurred, the selection of a per instance civil money penalty would be appropriate,” again, putting a limit (of sorts) on the fine.
Why do I believe this to be important information? I am not convinced a facility carefully documents all of its efforts and maintains a written summary and/or timeline of events to “take credit” for all that is done in response to self-identified issues. I believe you are doing it; I have lesser confidence that you can prove it. A facility must ensure that it not only maintains good documentation of its corrective efforts, but also feels confident in sharing sufficient evidence of those efforts during the survey process should an issue which occurred in the past be identified as a potential deficient practice.
A good administrative team will address deficient practices with a “plan of correction attitude”- ensuring the same thorough steps required to draft an acceptable plan of correction are followed whether “cited” during a survey or “self-identified” during the facility’s own quality improvement efforts. Make it a cornerstone of your management style. Applying a “plan of correction attitude” to issues as they arise (whether big or small) will condition your management team to adopt a certain mindset and ensure you are prepared to share sufficient evidence of your facility’s response to noncompliance.
Rebecca Bartle, RN, MSN, HFA
Compliance & Regulatory Affairs Consultant