1. Plans of Correction (PoC) Donna Tiberi, RN Standards Interpretation p: 312-202-8073 e: dtiberi@HFAP.org 1

2. Objectives Upon completion of this program, the participant will: 1. List the requirements for completing the Plan of Correction for approval 2. Identify the processes for submitting the Plans of Correction 3. List reasons for requests to revise Plans of Correction 2

3. Why is POC Required 1. CMS requirement 2. Compliance for Deficiencies 3. Demonstrate 3

4. When is POC Required 1. Every Condition-Level deficiency (CLD) 2. Every Standard-Level deficiency (SLD) 3. Any standard that was “Corrected during survey” 4

5. What is Submitted in a Successful POC? 1. Completed Template 2. Attachments – Requested Supporting Documents 5

6. When is POC Due? 1. Due date is provided on the emailed HFAP “Deficiency Report” 2. Due 10 calendar days after date of email 3. CMS Regulation 6

7. Where to Send PoC 1. Subject line: Your Facility Name – Plan of Correction 1. Lower case 2. If multiple emails: Label as “1 of 3” 3. Email to: reports@hfap.orgreports@hfap.org 7

8. Who is Responsible to Submit PoC 1. Accreditation Coordinator 2. Other Delegated personnel such as, Directors Manager Others 8

9. What is the Procedure for Submitting the PoC? 1. See the attachments sent with Email sent by Account Manager 2. Prepare one (1) Plan of Correction for EVERY deficiency cited-do not group 3. 15 Deficiencies = 15 Plans of Correction 4. Plan of Correction for a Condition-Level Deficiency: a) Include the PoC for each standard cited under the Condition b) In addition to the Plans of Correction for each separate standard 9

10. Instructions Provided with the Deficiency Report The Deficiency Email includes two attachments: 1. Instructions for Completing Plan of Correction 2. Plan of Correction – Template 10

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13. Section “Standard Number & Standard Verbiage” Copy the exact standard number and the exact verbiage into this section. 01.01.22 Contracted Services “The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the Contracted services.§482.12(e)”. 13

14. Section “Surveyor Comments” Copy the exact surveyor comment citation in this sections as noted in your survey deficiency report. Such as example: “This standard is not met as evidenced by: During the review of the QAPI program, it was noted that the hospital’s reference laboratory (Unity Point Meritor Reference Lab) had not submitted data to QAPI program. This was confirmed by the Director of the Lab and the Vice President for Performance Excellence.” 14

15. Section “Plan of Correction – Include Details & Timelines” Document / Process Revision: 1. Reference Laboratory added to contract list 2. Reference laboratory quality data added to QAPI program. Document / Process Approval: 1. Updated contract list and quality data will be presented to the BOD at the April 10, 2016 Meeting. Education on Document / Process: 1. Addition of reference laboratory included on list of contracts will be explained to the BOD (reference laboratory was deleted from list of contracts on recommendation of 2010 HFAP surveyor). Deficiency Status: (Select one: In process, resolved or compliant at time of survey). -In process -Completed on January 12, 2016 15

16. Plan of Correction Column The Plan of Correction column needs to have a commitment from the hospital that they will resolve the particular deficiency that was cited. While there is a requirement for Process Revision Process Approval Process for Education Ultimately the hospital needs to explain how they plan to resolve the deficiency. 16

17. Section “Responsible Person” Do not document personnel names, only use respective titles such as: Vice President Performance Excellence Emergency Department Director CNO CEO Infection Preventionist OR Surgical Director 17

18. Section “Expected Date of Completion” A. TERMS THAT ARE NOT ACCEPTED: “Ongoing” “Continue Monitoring” “In 3 months” B. Required Terminology – specific date(s) May 13, 2016 Acceptable: “3 rd Wednesday of each month”, e.g., Governing Body meetings 18

19. Section “Expected Date of Completion” C. Acceptable Terminology – For Monitoring Daily (for three months, then monthly) Weekly Monthly / Quarterly / Semi-Annual / Annual EDOC stands for “Expected Date of Completion” HFAP requires actual dates in the format of month/day/year, such as “June 7, 2016” or “6/7/2016”. Verbiage such as “Completed” or “2017” are not acceptable 19

20. Section “Monitoring & Reporting Plan” Include- Evidence Documents- such as purchase orders, or revised or new policy, etc. Implementation Monitoring Indicators 20

21. Section “Monitoring & Reporting Plan” Include Evidence Documents Implementation Monitoring Indicators Responsible Position Frequency 21

22. Attached Documents Labeling - identify each standard Separate file- each PoC should have its own file 22

23. Read Attached Instructions Please be sure to read all information submitted to you before you submit the Plans of Corrections. If the Plan of Correction is found to be incomplete, it may delay the PoC approval process 23

24. HFAP Review of Submitted Plan of Correction A. Condition-Level Deficiencies (CLD): 1. HFAP approves the POC within 10 business days 2. Notify facility if approved or if additional actions required B. Standard-level Deficiencies: 1. HFAP approves the POC prior to next Executive Committee 2. Within six weeks 24

25. Follow-up Surveys If a Condition-level deficiency (CLD): 1. Plan of Correction approved by HFAP 2. An unannounced, follow-up survey within 45 calendar days of date the Plan of Correction is due 3. Survey the Condition-Level deficiency – ONLY 4. Purpose: To determine the Plan of Correction for the CLD has been appropriately addressed 25

26. Appeal Deficiency Request Consideration to delete finding Identify reason and document evidence of compliance at time of survey in the PoC Plan of Correction 26

27. Request - Attachments 1. Please “highlight” or make notation to identity any changes to documents, e.g., modifications to policy 2. Labeling each document a) Standard 01.01.01 b) Standard 11.01.03 27

28. * Immediate Jeopardy 1. Mitigate situation during survey 2. HFAP Must Notify CMS 3. Plan of Correction 4. Refocused Survey – 45 days 5. Ongoing Interim Progress Reports 6. Resurvey – 1 year 28

29. Email: dtiberi@hfap.org@hfap.org Call: 1-312-202-8073 Info@hfap.org Visit our Website: www.hfap.orgwww.hfap.org 29