Features of an Acceptable Plan of Correction

The responses the facility submitted below are adequate so their PoC would be acceptable.

Required PoC Element

Facility's Response

Acceptable 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."

 

The incomplete investigations for non-serious injuries of unknown cause have been reopened. There was not a system in place to ensure thorough investigations.

Persons responsible: the facility director and director of quality services management (QSM)

The facility has investigated the cause for the deficiency and identified the specific system that was lacking.

 

The facility identified the staff responsible for implementing this phase of the plan.

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

The Preliminary Investigation Report for Injuries of Unknown Origin will be revised to ensure a more complete investigation and will be used when investigating non-serious injuries and injuries of unknown origin.

Unit directors (UDs), assistant unit directors (AUDs), management supervisors, campus coordinators, and the nurse manager for the facility will be in-serviced of the revision.

Persons Responsible: facility director and director of medical services.      

The facility stated the specific action they will take to correct the deficiency and how related information will be used in the future.

 

The training component ensures staff knows the new process.

 

The facility identified the staff responsible for implementing this phase of the plan.

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 facility director will conduct a monthly meeting with UDs/AUDs to critique investigations with regard to completeness.

If an injury report with a non-serious injury of unknown cause has not been investigated within 2 working days, the safety officer will notify the appropriate UD for action. Quality assurance staff will randomly monitor investigations for completeness. Any problems will be referred to the facility director for corrective action.

Persons Responsible: facility director and director of QSM

The facility established a system to monitor the plan's effectiveness and identified the responsible person.

 

They also established a tracking system to facilitate their investigations and identified responsible persons.

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

The QSM will be responsible for ensuring the implementation of the PoC.    

 

The facility identified the person(s) by title responsible for implementing the PoC.

The QSM will be responsible for the overall implementation.