How to Draft a Plan of Correction Do it quickly and make sure that it is executable BY ROBERT KURTZ


ct fast, and take it seriously. That is the advice that retired Medicare

surveyor and current regulatory and accreditation compliance consultant Bruce Ettinger, MD, of Santa Monica, California, has for ASCs that are required to submit a plan of correction (POC) to address deficiencies found during a Medicare survey. Ettinger is also an ASCA Board member. “You should work to respond as

rapidly as possible,” agrees John Goehle, CASC, chief operating officer of ASC consulting firm Ambulatory Healthcare Strategies in Rochester, New York. “It could take you all the time you are allotted to pull the information together that you will need to develop and submit the POC.” Any ASC that receives a statement of deficiencies—the document that identifies what needs to be corrected in an ASC following a Medicare sur- vey—should first compare the findings to the notes taken during the survey and exit conference, Goehle advises. “The state is required to tell you all deficien- cies before they leave your facility,” he says. “There should be no surprises or new deficiencies in the statement.” Before starting to work on the

POC, ASC staff should make sure they understand the deficiencies, Goehle continues. “If you have any confusion about your citations, call the state and ask for clarification.” There are two critical elements to a

POC, says Ettinger. “The first is the cor- rective action for each deficiency. You must explain your procedure for imple- menting immediate corrective action and preventing future occurrence.” As an example, Goehle says,

surveyors might find beds were not properly wiped clean following a procedure. “To address this deficiency, you might establish a process for a


member of your staff to check beds on a periodic basis to ensure they were wiped down properly. You must supply documentation to show how this will be performed, so you could develop and include a bed cleaning checklist.” Ettinger also advises including an appropriate policy. “Whenever surveyors return to a facility for a follow-up survey, the first thing they will ask for, especially to correct a deficiency, is a policy to confirm the

establishment of a new

process, and one that has been reviewed and approved by the governing body.” Make sure the actions you take to address a deficiency are appropriate, he says. “It is critical to know what is required by the regulations and inter- pretative guidelines so you can respond with a compliant corrective action.” The second critical element to a POC, Ettinger says, is monitoring and tracking procedures. “The POC must explain that there will be oversight to ensure ongoing compliance.” Goehle recommends including the area of deficiency in your ASC’s qual-

ity improvement (QI) program. “Your QI program is what monitors your regulatory compliance. If you fall out of compliance in the future, a good QI program will identify those prob- lems. Whenever I write up a plan, I make ongoing monitoring of any area of deficiency another checklist item in my QI program.” Ettinger advises ASCs to make sure

that what they state in their POC is actually what they can and will do. “Do not write a POC that you are unable to execute. That is unacceptable, and you will likely get into trouble during a future survey.” In the event that the original POC

fails to effectively address a defi- ciency, change the corrective action, he advises. “You are not bound by what you originally said in your POC. You are permitted to—and Medicare expects you to—continue to improve. Change your plan, justify why the plan was changed and document it. Always strive to do better.”

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