CMS Plan of Correction: Template and FAQ

The Centers for Medicare and Medicaid Services (CMS) conducts regular inspections to ensure that facilities participating in their programs comply with all regulations. If CMS identifies any deficiencies during this process, a facility must submit a Plan of Correction outlining how each deficiency will be addressed.
But, how exactly do you write a plan of correction, or PoC? In this article, we’ll answer frequently asked questions about this process and outline five key elements that will provide you with a helpful Plan of Correction template.
What Is a CMS Corrective Action Plan?
After a healthcare facility is surveyed by CMS, an administrator will receive a statement outlining each deficiency that was found during the visit. A PoC is the formal document that facilities must submit in response. It outlines the steps that the facility will take to correct each issue, demonstrating their compliance and commitment to preventing these issues from happening again.
How Do You Submit a Plan of Correction?
Facilities must use CMS’s statement of deficiencies and plan of correction form (CMS-2567) when outlining corrective actions. CMS surveyors use this form to cite and describe each violation, and facilities use the “plan of correction” column to respond to each citation. This form must be completed and returned to CMS within 10 calendar days of receiving any deficiencies.
Can You Use Other Plan of Correction Templates?
CMS requires the use of form CMS-2567 when formally responding to deficiencies. However, facilities can plan their responses using a corrective plan of action template to ensure consistency, comprehensiveness, and compliance.
CMS must approve of all corrective actions after they’re submitted. If there are any omissions or issues, facilities will need to provide revisions and may even undergo further disciplinary action. So, a planning template or checklist can be helpful to ensure that your responses cover all essential information.
How Do You Write a Correction Plan? 5 Required Elements
When responding to deficiencies, facilities must meet all CMS plan of correction requirements. Below we’ll outline five elements that should be addressed, as well as sample language in a plan of correction template for state survey deficiencies for additional guidance.
It’s important to note that all five of these elements must be included in your response to each cited deficiency. To provide context for our sample language, we’ll use an example deficiency in which a staff member did not perform proper hand hygiene before donning gloves.
1. Actions Taken
This section should outline all the actions that your facility took to address the cited deficiency. This should include:
- What immediate steps your facility took.
- The date on which each action was implemented.
- The staff members responsible for making the corrections.
Template: In response to F0000, nurse #10 was notified of their noncompliance with hand hygiene protocols on March 10th, 20xx. The nurse manager implemented immediate staff retraining on hand hygiene and PPE usage on March 12th, 20xx, which was led by the unit’s infection control specialist. The nurse manager also posted written reminders and instructions for hand hygiene in each resident’s room on March 13th, 20xx.
2. Identification of Affected Individuals
This section should specify who may have been impacted by the deficiency (omitting protected health information) and how your facility identified them. This should include:
- How the facility determined who was affected.
- The date on which these individuals were assessed/identified.
- The staff responsible for identification.
Template: Residents in rooms 1, 5, 8, 10, and 15 were cared for by nurse #10 and were therefore affected by this deficiency. These residents were identified by the unit’s charge nurse on March 10th, 20xx. Since then, these residents have been closely monitored by their assigned RNs on a daily basis for signs of infection.
3. Systemic Policy Changes
This section outlines how your facility plans to update policies to reflect your corrective actions. This should include:
- How your facility reviewed and revised policies to incorporate these changes.
- How current and new staff will be trained and informed of updated procedures.
- The dates on which these revisions were made and the title of staff members responsible for them.
Template: The nurse manager has reviewed and revised the unit’s hand hygiene and PPE protocols to include more robust compliance measures. These updates were approved by the Quality Assurance and Performance Improvement (QAPI) committee on March 15th, 20xx. The infection control team will conduct mandatory hand hygiene training sessions for staff during onboarding and on an annual basis. This training will also be updated annually by the nurse manager to reflect the unit’s latest policies.
4. Monitoring and Quality Assurance
This section should describe your facility’s plan for monitoring compliance to ensure that the same issue doesn’t happen again. This should include:
- How your corrective actions will be monitored and maintained.
- When and how often monitoring will occur.
- How and when findings will be reported to the QAPI committee.
- Further actions to be taken if goals are not met.
Template: Daily audits of hand hygiene and PPE practices for all nursing staff will be conducted by the unit’s infection control team starting March 20, 20xx. Results will be documented and reviewed during weekly QAPI committee meetings. If compliance rates fall below 90%, increased monitoring will be implemented by the infection control team. Staff members found to be noncompliant will undergo immediate retraining. Once compliance rates are consistently maintained above 90% for two consecutive weeks, the frequency of audits will be reduced to a quarterly basis.
5. Date of Completion
Finally, you’ll need to indicate the date on which you expect your corrective actions will be completed. This should be recorded on the last column on form CMS-2567.
Template: All corrective actions are expected to be completed by March 20, 20xx.
What Resources Should Facilities Use When Drafting PoCs?
While we’ve discussed five key elements and included plan of correction template language as a guide, it’s important to thoroughly review all of CMS’s guidance documents before drafting your responses. Access essential manuals and instructions related to the PoC process using the following links:
- Guidance on formatting plans of correction
- Review and approval process for plans of correction
- Medicare State Operations Manual
- Nursing home enforcement and PoC FAQ by CMS
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