How to draft an acceptable plan of correction
All licensed assisted living facilities, personal care homes, residential care facilities for the elderly and other senior living settings must face the stresses of licensure surveys, which confirm or deny the community's compliance with applicable state regulatory requirements.
Although the goal of each community is to receive no deficiencies at the conclusion of the survey, some communities fall short of meeting regulatory standards and must demonstrate how they are planning to achieve full compliance within an allotted period of time by completing and submitting the state-issued plan of correction, or POC. Here are some tips on how to craft the POC response, effectively manage your time in a deadline-filled process and ultimately demonstrate that your community has achieved full compliance with the applicable regulations.
1. Resolve the immediate deficiency.
This is a simple but an important step in the drafting process. Although the majority of the language used in your POC response may focus on the processes being established to ensure that the deficiency does not occur in the future, ensure first that you discuss how the issue that triggered the cited deficiency was resolved.
For example, if you were cited because a care plan was not updated for a specific resident, make sure you indicate in your response that that resident's care plan was reviewed and updated accordingly.
After you have addressed the immediate deficiency, address how this issue will be resolved on an ongoing basis (for instance, with audits, tracking and education).
2. Use exhibits.
Stating that you have implemented checklists and audit reports is one way to demonstrate compliance with cited regulations. Including that documentation with your POC response enhances your submission and demonstrates that you have put your words into action.
This does not mean you “document dump” numerous forms and checklists on the state licensing office. Use your best judgment when attaching exhibits, and make sure they support the position of full compliance you are presenting. They are a helpful tool when used properly.
3. Set realistic deadlines.
When establishing deadlines within a POC response, make sure to give yourself time to account for unexpected errors or delays. The last thing you want to do is submit an ambitious and unrealistic compliance date that could result in fines if not completed before a future scheduled or unscheduled re-inspection.
Typically, the state licensing office issues a date by which your facility must be in full compliance with the cited regulations. Use this date as the identified deadline for compliance tasks that will require time to adopt and implement.
It is important to remember that after the state-issued compliance deadline, a re-inspection may occur at any time, so establish a separate, internal compliance deadline earlier than the state-issued date to account for unexpected events that may cause delays.
4. Be specific.
Specificity is needed in your POC response to show the state licensing office how your community meets (or plans to meet) the requirements of each cited regulation. The more specific you are in the POC response, the more effective your response can be, which can translate to less follow-up from the state regarding your submission.
For example, if you are cited for an incomplete resident care plan and one of your corrective actions is to implement a care plan monitoring system, it is likely to be beneficial for you to indicate how frequently you intend to monitor the care plans, who is responsible for monitoring the care plans and how the monitoring will be documented.
5. Don't overpromise.
Do not present an elaborate corrective action plan that you will not be able to execute within the given time frame and that is overly burdensome on your staff.
I am not endorsing the position that you only need to meet the regulatory minimums regarding the care and services required to be provided to residents. Rather, my recommendation is to set realistic expectations on what you can accomplish within a set amount of time to ensure that you are fully compliant with all cited violations.
The state does not give you bonus points for going above and beyond the regulatory requirements for one of the cited violations if the remaining violations that were cited are not corrected during re-inspection.
These tips always should be followed in conjunction with any explicit instructions that accompany the POC. Some states give detailed instructions as to the content and formatting of the POC response, whereas others leave it up to the community to make that decision. Also, some states are more lenient than others when offering extensions to a POC response or compliance date. Determine your state's position on extensions. Do not rely on one being granted before you do so.
My final words of advice are to approach the POC response as an opportunity to build relationships with the state licensing office staff and demonstrate that you share their goal of ensuring that an exceptional (and compliant) level of safety and service is provided to all residents. Keeping this in mind as you navigate the drafting and implementation of your compliance program can make this process more positive and constructive. Good luck!
James Henry is staff counsel for Blue Harbor Senior Living, a national senior living management company based in Portland, OR. This article is meant to be used only as a guide and should not in any way overrule specific instructions provided by your state licensing agency or applicable state regulations regarding how to write and respond to a deficiency notice. The information presented in this article is for informational purposes only and not for the purpose of providing legal advice. Contact your attorney to obtain advice with respect to any particular issue or problem.
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