November, 2004

Information Bulletin 04-18
NH-108
CBC-36

Developing Written Acceptable Plans Of Correction for SNF/NFs

Purpose:

The purpose of this informational bulletin is to provide assistance to providers in preparing the acceptable plan of correction (POC) when federal deficiencies are issued for SNF/NFs.

Information Bulletin 95-2 no longer applies to SNF/NFs.

The Minnesota Department of Health (Department) or Centers for Medicare and Medicaid Services (CMS) issues a Statement of Deficiencies. The CMS-2567 identifies violations of the minimal federal regulations. The CMS-2567 identifies the federal regulation in violation and describes the findings of noncompliance. The facility is required to submit a written response to these deficiencies. This response is known as the Plan of Correction.

The Department or CMS must accept the POC in order to allow the facility to continue in the federal certification program. Approval by the Department or CMS of the POC is based on Section 7304D-Acceptable Plan of Correction from the 5/21/04 CMS State Operations Manual as stated below in italics. SNF/NFs must address all of these areas in order for the Department or CMS to accept the POC.

Acceptable Plan of Correction

Except in cases of past noncompliance, facilities having deficiencies (other than those at scope and severity level A) must submit an acceptable plan of correction before substantial compliance can be determined.

An acceptable plan of correction must:

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

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

  • Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur;

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

  • Include dates when corrective action will be completed. The corrective action completion dates must be acceptable to the State. If the plan of correction is unacceptable for any reason, the State will notify the facility. If the plan of correction is acceptable, the State will notify the facility. Facilities should be cautioned that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely. The plan of correction will serve as the facility's allegation of compliance.

  • The completed CMS-2567 with the plan of correction must be returned to the Department of Health within 10 calendar days of receipt. If the POC is not acceptable the facility will be contacted for clarifications and modifications. An acceptable plan of correction must be submitted and correction of all deficiencies made.

If you have any questions concerning this bulletin and/or completing a plan of correction, please contact your assigned Licensing and Certification or OHFC Supervisor, or call the Compliance Monitoring Division, Licensing and Certification Program (651) 201-4101.

Thank you for your assistance.

Updated Thursday, March 24, 2011 at 04:44PM