A hospice generally undergoes a survey once every 36 months, as conducted by a survey agency or an approved accrediting organization. These on-site surveys are often stressful. However, the tough job of a hospice doesn’t end there. After receiving the written Statement of Deficiencies – Form CMS-2567 (SOD), hospices are only given ten calendar days to complete and submit an effective Plan of Correction (POC) to address the alleged deficiencies discovered during the survey. This POC should be acceptable to surveyors to prevent serious consequences to the hospice, such as enforcement remedies (effective October 1, 2022) or the termination of its provider agreement. We know how stressful and tedious surveys can be for you. And so, to help you develop an effective POC, we’ll share with you the common reasons for their rejection and how you can avoid these from happening.
- No Completion Dates
The corrective action for each identified deficiency should have a “completion date,” and each completion date should be matched to a deficiency. In other words, it helps to include multiple completion dates for certain deficiencies. For example, a deficiency caused by a bad policy may need a few days to amend, while a deficiency that requires more time and more corrective actions may have staggered completion dates. By being specific about these completion dates, the hospice is more determined to prioritize corrective efforts to address its deficiencies.
- Extended Completion Dates
A surveyor can reject a POC for various reasons, including extended completion dates. As such, do not default to the projected maximum completion timeline. Do not also wait until a POC has been submitted or accepted before taking corrective actions. Instead, promptly implement them after the survey so the POC can reflect which actions are already in progress or have already been completed.
- Unrealistic Plan of Correction
Both the identified corrective measures and the stated compliance date must be feasible. Failure to achieve whatever you have written in the POC could result in more serious issues for your hospice agency, including a failed return visit. In essence, you want to avoid overpromising on corrections and completion dates. This means removing items that aren’t necessary for resolving the issues and setting a realistic deadline for compliance. It is worth noting that even if items are not included in a POC, the hospice may still take other activities voluntarily if it is in its best interest. The POC acts as a floor, not a ceiling, for the actions your agency can take.
- Insufficient Monitoring
Monitoring is an area that is frequently missed or covered too broadly in a POC, resulting in rejection. A monitoring procedure that declares that documents will be checked regularly to ensure compliance, for example, is likely to be rejected. The monitoring procedure should specify how outcomes will be measured so the effectiveness of the corrective action can be established. Who among your team will be informed of the monitoring procedure’s results, and what actions will be taken if further non-compliance is observed.
We hope you can put these suggestions to good use in your forthcoming surveys and Plans of Corrections. The software that is always at your side, Data Soft Logic, cares about your accomplishments, no matter how big or small. How well did your last survey go? Let us know about your experience to see how we can help you. Schedule a demo with us to learn more about our solutions.