ELEMENTS OF A PLAN OF CORRECTION AND PAST NON-COMPLIANCE STATE OF MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BUREAU OF HEALTH SYSTEMS

WELCOME

PRESENTERS: ALICE B. TURNER, DIVISION DIRECTOR NURSING HOME MONITORING DIVISION KAREN J. ANTHONY, ASSISTANT DIVISION DIRECTOR

OBJECTIVES: HOW TO WRITE A PLAN OF CORRECTION (PoC) Content of the PoC Resident-Centered Deficiencies Facility-Centered Deficiencies PoC Completion Dates Disputing Deficiencies PoC as Allegation of Compliance Attachments to PoC Questions Regarding the PoC Process Compliance Date Determination Examples of Information NOT Applicable to the PoC

HOW TO WRITE A PoC Why a Plan of Correction? To encourage facilities to correct deficiencies as soon as possible. Commitment to correct each deficiency by a specific completion date. Submission of an acceptable PoC is required for all deficiencies of scope and severity Levels B through L.

Fax copies of PoCs are not approved. Why? The quality of faxed copies vary Original document must be sent to the correct address as identified in the cover letter.

Plan of Correction (PoC) A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to Antoinette Ellis, Licensing Officer, Bureau of Health Systems, MDCH, (mailing address) P.O. Box 02981, Detroit, Michigan 48202 or (street address) Cadillac Place, Suite 11-150, 3026 W. Grand Blvd., Detroit, Michigan 48202. Failure to submit an acceptable POC by April 4, 2009 may result in immediate imposition of Category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions. A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to Catherine Hunter, Licensing Officer, Bureau of Health Systems, MDCH, (street address) Alpine Executive Center, S-108, 400 W. Main Street, Gaylord, Michigan 49735. Failure to submit an acceptable PoC by June 28, 2009 may result in immediate imposition of category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions. A PoC for the deficiencies must be submitted within 10 calendar days from the receipt of CMS-2567 report to Timothy D. Smith, Licensing Officer, Bureau of Health Systems, MDCH, (street address) 1808 W. Saginaw Street, Lansing, Michigan 48915. Failure to submit an acceptable PoC by February 15, 2009 may result in immediate imposition of category 1 enforcement remedies (State Monitoring, Directed Plan of Correction and/or Directed Inservice Training) or other enforcement actions.

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

Resident-Centered Deficiencies Are violations of requirements that must be met for each resident.

EXAMPLES of such deficiencies include failure to: Prevent pressure sores Protect the dignity of residents Provide notice prior to transfer Adequately assess residents

Element 1: the PoC for resident-centered deficiencies should give a general accounting of how the deficiencies cited during the survey for a specific resident have been corrected. It should be noted that the residents cited represent those examples discovered from the resident samples used in the survey. Element 2: must state how all other residents who have been, or could be, affected by the generic deficient practice have been identified. Element 3 and 4: must demonstrate that the facility has considered all residents in their plan of development.

Corrective measures facilities should consider for Element 3 of their PoC include, but are not limited to: In-service training Off-site training Information sharing with other facilities Use of consultants Interdisciplinary, multi-level quality improvement teams Resident Council input Ombudsman input Physical environment enhancements Expansion of staff numbers/qualifications Staff supervision and discipline

Corrective measures facilities should consider for Element 4 of their PoC include, but are not limited to: Oversight by DON or other management personnel Customer surveys Resident Council feedback Ombudsman feedback Interviews with residents and families

Facility-Centered Deficiencies In general, these are “system” deficiencies such as: Lack of an infection control program Inadequate staffing An inoperative fire alarm system

Facility-Centered Deficiencies Element 1: How corrective action has been or will be accomplished for the facility-centered deficient practice; Element 2: What measures have been or will be put into place or systemic changes made to ensure that the deficient practice will not recur; and Element 3: How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur; i.e.; what quality assurance program will be put into place. Note: Some regulatory requirements (Example: F-248) deal with both individual residents AND facility systems. For deficiencies that have both facets, be sure to address each facet in the corrective response.

PoC Completion Dates 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.

Disputing Deficiencies Level 1: Before surveyors leave the facility, not after you receive 2567. Level 2: Please refer to the MDCH Informal Deficiency Dispute Resolution for LTC Facilities document for the process of submitting Level 2 requests for IDR review of deficiencies. If a Level 2 request is submitted for a deficiency, the facility may acknowledge its submission by placing the following statement at the beginning of the PoC for each deficiency in question. “The facility objects to this deficiency and has invoked its’ right to utilize the Informal Deficiency Dispute Resolution process for Tag ____”. (See page 10 of the Guidelines.) You may request the IDR be reviewed by either the Bureau of Health Systems or MPRO.

INFORMAL DEFICIENCY REVIEW REQUEST – LEVEL 2 HANDOUT

PoC used as an Allegation of Compliance The PoC is automatically considered to be the facility’s allegation of compliance as of the latest PoC correction date given in the PoC If you use several dates, the latest date is automatically used

Attachments to the PoC Restrict PoC attachments to those documents that are necessary to support the specific contents contained with the Poc Extraneous materials are of no value and may result in unnecessary delays to the process

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

Questions Regarding the PoC Process Facility questions regarding all aspects of the PoC process may be directed to the Licensing Officer: Detroit Office – Antoinette Ellis Gaylord Office – Catherine Hunter Lansing Officer – Timothy Smith Questions related to the Complaint PoC should be directed to the Manager of the Complaint Investigation Unit – John Rojeski

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 The facility is in substantial compliance, 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 and verification of an earlier compliance cannot be determined 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 in Lieu of Revisit In some cases, acceptable level 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.

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

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

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

Criteria for Past Non-Compliance cont. 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. 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.

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.

FACILITY PAST NON-COMPLIANCE CHECKLIST HANDOUT

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

Documentation of Past Non-Compliance cont. 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. 4. No PoC is required for past non-compliance citations. No revisit is conducted for past non-compliance citations.

Facility Past Non-Compliance Checklist (This is a tool, not a required document.) 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 recur 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

Enforcement Related to Past-Non Compliance NOTE: Enforcement Action on Immediate Jeopardy Past Non-Compliance 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) will be cited.

INFORMAL DEFICIENCY REVIEW (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.

QUESTIONS ?

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.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf Appendix PP http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf