Features of an Unacceptable Plan of Correction

The responses below the facility submitted are inadequate. Therefore, they will be unacceptable.

Required PoC Element

Facility's Response

Unacceptable Response

First element, " PoC must contain the plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited."

 

A facility representative will assess Individual #1 at the day habilitation center, and his interdisciplinary team (IDT) will meet to review and discuss the findings of the assessment.

The facility did not address the specific corrective measures necessary for ensuring the day habilitation center would meet Individual #1's needs.

The plan only states that the facility will assess the individual at the center, but does not state what measures will be taken to correct the deficient practice. It also does not address the processes that led to this deficiency.

Second element, "PoC must contain the procedure for implementing the acceptable PoC for the specific deficiency cited."

At Individual #1's annual planning conference, the day habilitation center assessments, staff observations, and review of client performance will be discussed.

The facility did not indicate the specific strategies it would use to ensure the deficient practice would not reoccur.

The facility plan only calls for annual review of the program, rather than stating specific systemic changes designed to prevent recurrence.

Third element, " PoC must contain the monitoring procedure to ensure that the PoC is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements."

The administrator will ensure proper monitoring.

 

The monitoring strategy is not specific.

It merely states that the administrator will ensure that monitoring occurs.

Fourth element, "PoC must contain the title of the person responsible for implementing the acceptable PoC."

Sarah will handle the implementation.  

 

A name, instead of a title, is used as an identifier of who will be responsible for implementing the PoC.

It states Sarah will be responsible for implementation.