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A healthcare plan of correction is an unfortunate wake up call. At some point, nearly every facility must complete one, especially in long-term care where CMS data shows that nearly every active nursing home has received a deficiency in the past three years (28% were for actual harm or jeopardy).
When your time comes, I recommend including technology as part of the plan.
Why? Most compliance systems fail over time because they are based on the skills of an individual or they have stretched the limits of a program that the organization has outgrown. By including the adoption of new technology in your plan of correction, you are signaling clear change that is easily maintained even with evolving compliance needs and regulations.
The short period of time to make corrections after a notification often means organizations rush to a solution without considering how technology can ensure ongoing compliance. In this article, I’ll help you change course — showing you both the value of technology in a healthcare plan of correction and also how to incorporate it into plans for the most common deficiencies.
What Is a Plan of Correction in Healthcare Compliance?
A statement of deficiencies and plan of correction refers to a document submitted by a healthcare facility to the regulatory or accreditation agency outlining the actions that the organization will take to rectify deficiencies identified during a survey. Plans of correction are common in Centers for Medicare and Medicaid (CMS) surveys. The document details the specific steps to correct issues and the timeline for completion, as well as ongoing monitoring for compliance.
A healthcare plan of correction (PoC) is required for specific deficiencies cited during an inspection and is based on the surveyors’ professional knowledge and interpretation of Medicare and/or Medicaid or Clinical Laboratory Improvement Amendments (CLIA) requirements.
In my 30+ years of healthcare management experience, I have attended hundreds of accreditation surveys and CMS audits, some of which required a plan of correction. Following the audit, leaders typically conduct a root-cause analysis. Depending on the severity and scope of the deficiencies, corrective action would be taken or planned, and the PoC would be submitted.
The Role of Technology in a Corrective Action Plan
Getting a deficiency is like being handed a “hot potato” — you can’t wait to “fix” the issue and get beyond the embarrassment and risk to the organization. It’s this additional pressure that causes many organizations to take quick action, rather than identifying a solid solution. The role of technology in a plan of corrective action becomes more obvious when you look at the reason(s) why the organization was unable to maintain compliance.
Start by asking yourself these questions:
- What processes contributed to the deficiency?
- How many programs / systems does my compliance program utilize?
- Am I relying on reports or information from multiple sources?
- Are corrections sustainable with my current programs / systems?
Compliance deficiencies that result in CMS tags are often the result of failed processes that include a lack of resources and standardized workflows that address organizational and individual roles and responsibilities. For example, infection control and prevention deficiencies are often a direct result of outdated policies, training, and ongoing surveillance failures that can result in Immediate Jeopardy (the most serious CMS F-tag level) because it has caused or is likely to cause serious injury, harm, impairment or death to a resident/patient. This deficiency probably means your training plan didn’t adequately prepare staff or your process for knowing when to update the plan failed. Correcting these issues with technology is a fix for the process — automating reminders and workflows so you aren’t relying on one person or a disjointed system.
In my experience, these systemic changes are what CMS (and other agencies) are looking for in corrective action plans.
Adding Technology to Plans of Correction for the Most Common Accreditation Deficiencies
Infection Control Issues
Infection control deficiencies usually focus on failure to maintain an infection control and prevention program which requires written policies, governing body approval, and for some organizations, oversight from a qualified infection preventionist. These types of non-compliance can lead to increased rates of healthcare-associated infections, a major problem in today’s healthcare system. Antibiotic stewardship and immunization records also fall within this category.
How Technology Can Be Incorporated Into a Plan of Correction
The best answer to the types of deficiencies listed above is a document management system built for healthcare. Instead of multiple tools to handle document creation, board approval, staff acknowledgment, storage, and reporting — it’s all in one compliance platform. An automated approval process keeps things on track and document expiration reminders ensure you don’t forget. Plus employees have access to infection control policies, job descriptions, and job aids. When surveyors ask your employees a question, the employee can retrieve a policy and explain their role and responsibilities. This demonstrates that the organization is serious about keeping staff informed and documentation organized.
This is the checklist you need to eliminate infection control deficiencies.
Patient Rights Violations
Patient rights are becoming more complicated at a federal and state level, especially with the increase in state health privacy laws. This also means deficiencies are on the rise, especially related to upholding patient rights, including informed consent, privacy, and respect for patient autonomy. New HIPAA rules in 2024 (HIPAA Final Rule for Reproductive Health Privacy and Confidentiality of Substance Abuse Disorder) are examples of sweeping regulations with very strict requirements that impact multiple processes.
How Technology Can Be Incorporated Into a Plan of Correction
As mentioned above, document management software can improve upon existing processes that have failed. Since it is simple to update policies, fillable forms, and agency guidance (sources of truth), document management systems can reduce confusion and help to build staff confidence.
Medication Management Problems
These are deficiencies related to the safe storage, administration, and documentation of medications, including errors in prescribing or administering drugs. To reduce the risk of medication-related compliance failures, a careful balance of technology and human oversight is recommended to optimize workflows.
How Technology Can Be Incorporated Into a Plan of Correction
There are many technology solutions that aid medication management. These include computerized physician order entry (CPOE), barcode medication administration, electronic reconciliation, automated dispensing systems, and automated drug-interaction alerts. Be sure to incorporate learning and decision-support resources to improve patient motivation and self-activation.
Quality of Care Deficiencies
These deficiencies are inadequate processes for assessing and improving the quality of care, including failure to monitor patient outcomes and implement necessary improvements. Unfortunately, quality of care deficiencies are often discovered during an inspection and are often based on the direct observations of the surveyor. I call this compliance sufficiency. As a compliance professional, you’ve “checked the boxes,” but employees are not demonstrating readiness. You have many options for a quick fix, but what you really need to do is correct both the compliance attitudes and employee habits that are not always visible.
How Technology Can Be Incorporated Into a Plan of Correction
There are a variety of technology/software solutions that are embedded or can be added to the Electronic Health Record (EHR) to identify risks based patient-assessements, test results, specialist consults, and the progression of the disease or condition. However, in the case of deficiencies observed by the surveyor, you need technology that will address the root of the issue — employee habits. This might come in the form of electronic incident reporting, more consistent training through a learning management system (LMS), or accessibility to existing policies and procedures. Being able to point to a resource, like an LMS, in a plan of correction shows that you’re able to quickly implement change.
Safety and Environment Hazards
Also common are deficiencies related to non-compliance with safety regulations regarding the physical environment, such as inadequate emergency preparedness, unsafe patient handling, or hazardous materials management. Many healthcare organizations have members of the management team who are responsible for management of safety and environment hazards, but they rely on staff to report unsafe/non-working equipment and systems.
How Technology Can Be Incorporated Into a Plan of Correction
The “work order” system generally works if unsafe conditions are reported and there are resources available for correction. Introducing incident reporting software as part of a healthcare plan of correction often helps the root issues that caused the deficiency. Software offers truly confidential reporting and automation, which gives employees confidence in their anonymity and ensures the reports will be moved up the chain of command in a timely manner.
Correct Deficiencies Using MedTrainer
A healthcare plan of correction provides an opportunity to introduce new technology and processes as a long-term compliance solution. If you’re currently using multiple tools to manage workforce compliance, this is the time to make the move to a single platform.
MedTrainer’s all-in-one compliance platform helps healthcare organizations hold themselves and employees accountable with automation, customizable workflows, and end-to-end document management that keep you aligned with quality improvement goals. With MedTrainer, you have:
- Access and transparency for all stakeholders
- Automated onboarding based on the staff role
- Real-time reporting that is customizable
- And so much more