Other Plan of Correction Issues and Reiteration
For every deficiency or violation cited, a PoC must be provided. The PoC must include all PoC elements.
- For all deficiencies or violations, an anticipated date of completion must be provided for each tag on each form.
- Each deficiency/violation may have its own anticipated date of completion, which may be different from each of the other deficiencies/violations listed on the CMS-2567 or the DADS-3724.
- For example: the anticipated date of completion for W473 may be 07/12/16, and the anticipated date of completion for W120 may be 07/31/16.
When identifying in-service training as part of a PoC, the facility should indicate:
- who will conduct the training;
- what the content of the training will include;
- when and how often the training will be provided; and
- how performance will be monitored to ensure elements addressed in the training were implemented accurately and consistently.
Facilities should submit realistic plans of correction. Facilities should not submit plans of correction that they are not able to implement.
The PoC must identify the title of the staff person responsible for any actions or processes implemented.
The PoC must identify how corrections will be monitored and the staff person responsible for the monitoring.