• TS: – CMS: Preparing a Plan of Correction[®] [REF: CMS, CJCP, GB, JCSC, LDR] The Source, November 2013, Vol 11, #11, Pg 16 JCs1311_B7

Now that TJC has deemed status from CMS for the two special Conditions of Participation for psychiatric hospitals, most CMS requirements will be evaluated via TJC survey. However, it is still possible to receive a CMS survey (e.g., CMS random validation survey).  If CMS surveyors identify a condition-level deficiency, a formal plan of correction (POC) will be required within 10 calendar days.  This article identifies 4 key elements that should be included in every POC and shares a number of additional recommendations for more effective POC preparation such as:

• Take detailed exit conference notes to support getting started on the POC immediately
• Use language in the POC that mirrors that in the citation and address every point
• Create a checklist of each action indicated in the POC that includes due dates and responsible parties

The article also describes the difference in responding to condition-level findings made during TJC survey and the CMS requirement that such findings also trigger citation of leadership and the governing body at LD.01.03.01
Tip: Download this article and keep as a reference for the preparation of a CMS Plan of Correction.  Alternately, SPHCC Members can retrieve the article at any time via a link in our CMS library.
Tip: Make sure you have a dedicated scribe/minute taker/recorder for all daily briefings and exit conferences.  Yes, you may also use recording devices if you announce this in advance and arrange for surveyors to also have copies BUT, this tends to be intimidating/threatening to surveyors and should be avoided in all but the most dire (e.g., nothing more to lose) situations.