Documentation Power Tools                                                   25 years experience in long term care

4 Easy Steps to Writing an Effective Plan of Correction

When a facility is cited for deficiencies, the administration of the facility is required to complete a written Plan of Correction explaining how and when the non-compliance will be corrected. A good Plan of Correction is expected to clearly state the problem, set specific goals to solve the problem, identify trends and patterns, look at root causes, and monitor progress. Surveyors will examine what continuous quality improvement system the facility has in place to monitor its performance in identifying deficient practice and care and assuring it does not recur.

According to the State Operations Manual, Survey Procedures for Long Term Care Facilities, §7304, CMS, May, 2004, an acceptable Plan of Correction must: 

Address how corrective action will be accomplished for those residents found to have been effected by the deficient practice;

Address how the facility will identify other residents having the potential to be affected by the same deficient practice; 

Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The plan of correction is integrated into the quality assurance program; and

Include dates when corrective action will be completed.

This  is easily manageable when broken down into logical steps: 

1. Examine the policies and procedures related to the practices.

Are they clear, specific, and based on current professional standards and guidelines of practice?

Are they readily available to staff members?

Are all staff members familiar with them?

Do staff members need inservices on them?

Do they need to be rewritten or updated?

2. Evaluate the actual staff practices in the facility.

Are staff members following policy and procedure?

Do they need counseling or training?

Is management adequately monitoring staff practices?

3. Review the facility’s Quality Assurance program.

Are regular audits performed to monitor facility practices?

Are the audits specific enough to identify problem areas?

Are audit results examined by management, and acted upon in a timely manner?

4. Evaluate the forms and tools used by the facility.

Do the forms contain all of the essential information?

Are the forms logically organized and easy to use?

Are there forms for assessment, monitoring, tracking, evaluating, and auditing?

Following these four steps will make writing an effective Plan of Correction easier, and will also help to improve facility practices, policies, and procedures overall.

 More information about the plan of correction can be found in the book:

DON's Handbook for Long Term Care

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