Accreditation

Providing backup materials helps hospitals prove point after survey, correct cited deficiencies

Briefings on The Joint Commission, February 1, 2006

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Learning objectives : After reading this article, you will be able to

1. describe how to write a plan of correction

2. explain the process for receiving and responding to deficiencies

3. define the follow-up process after submitting a plan of correction

The devil is in the details, and when it comes to re sponding to deficiencies after a Centers for Medicare & Medicaid Services (CMS) survey, providing detail will put the hospital in a position to get the citation overturned.

"You can be as innovative as you want to be," says Jeffrey Coleman, a former CMS surveyor in New York state. "[Responding to survey deficiencies is] not just correcting the deficiency--it's preventing it [from occurring in the future]."

Hospitals must outline in their plans of correction that they will fix the deficiency by a certain date and de scribe the steps they will take to fix it, Coleman says.

After a CMS survey, hospitals will receive a statement of deficiencies, which outlines areas in which surveyors may have found a hospital to be noncompliant. Hospitals then have 10 calendar days from the date they received the statement to respond with a plan of correction.

If the state survey agency contracted by CMS to conduct the evaluation is satisfied with the plan of correction, it will overturn the deficiency (see p. 6 for a sample plan of correction).

Back it up

Part of the innovation required to correct a deficiency includes providing support materials when submitting a plan of correction.

Judy Sikes, PhD, CPHQ, director of accreditation and medical staff services at Parkview Medical Center in Pueblo, CO, includes attachments with her plans of correction to provide additional proof that the hospital has fixed the problem and will prevent it from occurring again.

For example, if a deficiency is related to chart review, Sikes will say that a plan of correction includes education with nurses and weekly chart monitoring for the next three months, she says.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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