Mastering Home Health Correction Plans: A Step-by-Step Guide

A Plan of Correction (PoC) is a formal response to a statement of deficiencies (often from a health care or regulatory audit). It outlines how you will address identified issues and ensure they don’t recur. To be effective, a PoC must address the "Who, What, Where, When, and How" of the correction.

1. Address the Immediate Correction

Detail the specific actions taken to fix the individual deficiency cited in the report.

· Identify the specific instance: State exactly what was corrected for the particular patient, record, or area mentioned.

· Timeline: Include the date the immediate fix was completed.

2. Identify Other Vulnerable Areas

Regulators want to know you looked beyond the one mistake they found.

· Conduct a sweep: Explain how you checked other similar records, residents, or equipment to ensure the problem isn't widespread.

· Example: "On [Date], the Director of Nursing audited all medication carts to ensure no other expired vials were present."

3. Implement Systemic Changes

This is the "root cause" section. Explain what new processes or training will prevent a recurrence.

· Policy updates: Mention if you revised an existing policy or created a new one.

· Staff Education: Detail who was trained, what they were taught, and when the training occurred.

4. Monitor for Quality Assurance (QA)

Explain how you will verify that the fix is working.

· Auditing schedule: State how often you will audit (e.g., weekly for 4 weeks, then monthly).

· Accountability: Name the specific job title (e.g., "The Quality Assurance Manager") responsible for overseeing the audits.

· Thresholds: Define what happens if the audits show the problem is returning.

Tips for Success

· Be Concise: Use clear, professional language. Avoid "fluff" or defensive explanations.

· Include Dates: Every action must have a specific completion date.

· Avoid "We Will": Use "The facility has..." or "The [Title] updated..." to show that action is already underway.

· Include education for staff as appropriate: To make sure the “fix” is permanent, education must be specific to the issue found in the citation and demonstrate that staff understand the issue and the corrections. Routine audits will need to be conducted to ensure that staff are compliant with the corrections.

Plans for correction can seem overwhelming and difficult. If you are struggling with creating a plan of correction for findings in a survey, contact Kenyon HomeCare Consulting at 206-721- 5091 or email gkenyon@kenyonhcc.com.