State of Michigan Department of Community Health Bureau of Health Systems Division of Operations Roxanne Perry April 12, 2011

ELEMENTS OF A PLAN OF CORRECTION, EVIDENCE Of COMPLIANCE IN LIEU OF REVISIT, AND PAST NON-COMPLIANCE Welcome

OBJECTIVES: State the essential elements of an acceptable Plan of Correction Discuss Evidence of Compliance in Lieu of a Revisit Identify the requirements for Past Non-Compliance

General PoC Guidelines 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.

General PoC Guidelines Submission of an acceptable PoC is required for all deficiencies of scope and severity Levels B through L. Commitment to correct each deficiency by a certain date. You may only have one date of compliance per deficiency.

General PoC Guidelines Resident or staff identifiers used by MDCH in the statement of deficiencies may be used in the PoC. The required content of the PoC for each deficiency depends upon whether the deficiency is resident-centered or facility-centered.

General PoC Guidelines 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.

Four Elements of a Plan of Correction 1. How corrective has been or/will be accomplished for those residents that were affected by the deficient practice.

Four Elements of a Plan of Correction 2. How the facility has identified or will identify other residents that have the same potential to be affected by the deficient practice.

Four Elements of a Plan of Correction 3. What measures or systemic changes have been or will be put in place to ensure that the deficient practice will not recur.

Four Elements of a Plan of Correction 4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur.

Resident-Centered Deficiency Examples include: failure to prevent pressure ulcers, protect dignity of resident. Element #1 - What did you do for the resident involved? Element #2 – What are you doing for like residents? Other examples include: provide notice prior to transfer, adequately assess residents

Resident-Centered Deficiency Element #3 – What systemic changes or measures have been put in place that would provide care and protect everyone? Examples include: In-service training, expansion of staff, physical environment changes, off site training Other examples include: staff supervision and discipline, resident council input, Interdisciplinary, multi-level quality improvement teams, use of consultants

Resident-Centered Deficiency Element #4 – How will you monitor corrective actions? Examples include: Oversight by DON or other management personnel, through quality assurance committee. Other examples include: resident council feedback, interviews with residents and families, surveillance

Facility-Centered Deficiency Examples include: environmental, staffing. Element #1 – How corrective action has been or will be accomplished for the facility deficient practice?

Facility-Centered Deficiency Element #2 – What systemic changes or measures have been put in place that would protect everyone? Examples include: In-service training, expansion of staff, physical environment changes, off site training. Other examples include: staff supervision and discipline, resident council input, Interdisciplinary, multi-level quality improvement teams, use of consultants

Facility-Centered Deficiency Element #3 – How will you monitor corrective actions? Examples include: Oversight by DON or other management personnel, through quality assurance committee. Other examples include: resident council feedback, interviews with residents and families, surveillance

Questions Regarding the PoC Process Facility questions regarding all aspects of the PoC process may be directed to the Licensing Officer/Manager: Detroit Office – Mattie Warren Gaylord Office – Laura Bauer Lansing Officer – Timothy Smith Complaint Investigation Unit – John Rojeski Other options include the survey monitors. As a last resort, Howard Schaefer (Director of NHM) or myself could be contacted.

Revisits Revists may be conducted at any time for any level of non-compliance. Revists are required for: 1) Non-Compliance at F (Substandard Quality of Care) 2) Harm level citations 3) Immediate Jeopardy

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 There are no new deficiencies, and The facility provides acceptable evidence to establish a correction prior to the first or second revisit date

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.

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, 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.

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

Evidence of Compliance In Lieu of a Revisit (Attestation)

Evidence in Lieu of Revisit In some cases, evidence 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. See CMS guidelines.

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

Elements of Past Non-Compliance

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 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

Criteria for Past Non-Compliance cont’d 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.

Facility Past Non-Compliance Checklist Date of Report: Administrator Name: Facility name: Address: Phone #: Resident Name: Date of Birth: Room #: Diagnosis: Date of event: Was the resident injured? If yes –Describe injury:

Facility Past Non-Compliance Checklist Cont’d 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 occur 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

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

Documentation of Past Non-Compliance (cont.) NOTE: The generic F698 has been discontinued Enforcement Action on Immediate Jeopardy Past Non-Compliance 1. 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) may be cited.

Documentation of Past Non-Compliance (cont.) 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.

Putting it all together When to give surveyor the PNC packet? If I give the surveyor a PNC packet why do they continue to investigate? Who accepts/rejects the PNC packet? Give packet at the beginning, during or end. Surveyors continue to investigate as the PNC may not be accepted. We are still obligated to complete the investigation – could go before an ALJ to determine if the survey process was followed. A manager decides if the PNC packet is accepted or rejected.

Bureau of Health Systems State Operations Manual (CMS) RESOURCES Bureau of Health Systems http://www.michigan.gov/bhs State Operations Manual (CMS) Appendix P http://cms.gov/manuals/Downloads/som107ap_p_ltcf.pdf Appendix PP http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

State Operations Manual (CMS) RESOURCES State Operations Manual (CMS) Appendix PP http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf PNC Chapter 7 of SOM http://www.cms.gov/manuals/downloads/som107c07.pdf