In a June 6, 2024 CMS Admin Memo, The Centers for Medicare and Medicaid Services (CMS) announced revisions related to the review and approval process for Plans of Corrections for certain citations. CMS states in the Memo that while Plans of Correction (POCs) are one element of the compliance review for issues identified on a survey, that POCs are not the main driver on a compliance determination. Facilities are expected to develop and implement POCs since the POC is their allegation of compliance, however, when a mandatory onsite visit is required to determine compliance, CMS states that it is unable to determine compliance solely by reviewing a POC. Interestingly, the Memo states that “neither CMS nor the State have the resources to play the consultative role” that multiple reviews of Plans of Correction convey. This indicates that many providers are not aware of how to write an acceptable POC.
CMS notes that if a State or CMS is unable to approve a POC after two submissions, then the facility should be contacted to notify them of the intention to request a revisit and confirm their readiness. A revisit survey should then be performed onsite, with the completion dates listed on the most recent POC submitted used as the compliance dates, once it has been verified by an onsite visit. The Memo states that when non-compliance is cited at a level where a mandatory onsite revisit is required to verify correction and compliance, CMS and the State Agencies (SAs) should prioritize the revisit surveys as the primary means of assessing compliance. Specifically, the Memo states that the revisit survey should be utilized versus “reviewing multiple submissions of a POC” for approval. This is because the review and subsequent rejection of “multiple” POCs submitted by facilities has increased the burden on both the providers as well as State Agencies and CMS.
Mandatory Onsite Visits
Not sure when an onsite revisit is required? Per Chapter 7 of The State Operations Manual (SOM), a mandatory onsite visit is required when:
- Deficiencies that constitute substandard quality of care (SQC), harm or immediate jeopardy (IJ) are identified during a survey. Even if a deficiency is lowered to a different level of noncompliance, onsite visits are still required. If the first onsite visit finds that the facility is in substantial compliance with the tags cited, then onsite visits do not need to be continued for any other tags that were cited at a scope and severity (S/S) below an F.
- The first onsite revisit identifies deficiencies that constitute SQC, harm or IJ. Onsite revisits will continue for those tags even if their S/S is lowered.
- A second onsite revisit identifies any noncompliance.
If a third onsite revisit would be required, the State Agency needs to get approval from the CMS regional office – or recommend that the facility be terminated from Medicare and Medicaid.
Situations Where This Memo is Not Applicable
The Admin Memo also provides a list of scenarios where the guidance above is not applicable. This list includes, but is not limited to:
- Plan of Removal process for Immediate Jeopardy
- When a Directed Plan of Correction has been imposed as an enforcement remedy
- When a survey has identified deficiencies where only a desk review is required to determine compliance via a review of the POC
Read the June 6, 2024 Admin Memo (Admin Info-24-14-ALL), “Revisions to the Review and Approval of Plans of Correction (POCSs) and CLIA Allegations of Compliance (AOCs) here.
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