Got a Plan of Correction? Follow These Implementation Tips

By Caralyn Davis, Staff Writer - November 17, 2020

Writing a plan of correction that will be accepted by the state survey agency is the first half of the battle to deal with any citations that the survey team hands out on the statement of deficiencies (form CMS-2567) in situations that don’t involve immediate jeopardy (IJ), says Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a partner in the Benesch Healthcare+ Practice Group at Benesch, Friedlander, Coplan & Aronoff in Columbus, OH. Note: Learn more about how to write a plan of correction that reduces negative impacts from survey in the AADNS Navigator article, “Writing a Plan of Correction: Keys to Success.”


The second half of the battle is successful, ongoing implementation of the plan of correction—and the stakes can be high. “While the plan of correction serves as the facility’s allegation of compliance in non-immediate jeopardy cases, substantial compliance cannot be certified and any remedies imposed cannot be lifted until facility compliance has been verified,” states the Centers for Medicare & Medicaid Services (CMS) in section 7317.1, Verifying Facility Compliance, of Chapter 7, “Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities,” of the State Operations Manual (SOM).


Note: Section 7317.2, Revisits, in chapter 7 of the SOM includes a chart that explains how surveyors certify compliance, the role of onsite revisits, and required remedies, up to and including the provider’s termination from the Medicare and Medicaid programs. In addition, section 7600, Continuation of Payments During Correction, addresses payment scenarios where states pursue alternative remedies to termination, and facilities do or don’t take corrective action according to the approved plan of correction and do or don’t achieve substantial compliance. Further, the August 17 Quality, Safety, & Oversight (QSO) memo QSO-20-35-ALL reviews changes to the revisit policy during the COVID-19 public health emergency.