Providers must demonstrate compliance with state, federal and accrediting body requirements as well as demonstrate continued compliance, implementing corrective actions and follow up measures to ensure the deficient practices do not recur. Participation in state and Medicare programs mandates that agencies take the initiative and responsibility for monitoring their own performance continuously so they are always substantially in compliance with regulation.

 

A deficiency is a failure on the part of the agency to meet federal and state regulations and accrediting body standards. Deficiencies have 3 components:

 

1. A regulatory reference.

2. A deficient practice statement, and

3. Relevant evidence or findings

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Sample Deficiency

Tag 543 – CFR 418.56(b) – All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by patient clinical record review which revealed that the plan of care developed after the various assessments were completed was not updated as patient’s condition changed in 4 of 11 (36%) of the records. This finding was validated the DON.

 

1st component – Regulatory Reference

The regulatory reference includes the survey tag (L tag), indicates the references and describes the requirements that are to be met by the agency. L tags are interpretive guidelines.

 

2nd component – Deficient Practice Statement

The deficient practice statement indicates the part of the requirement that was not met. It summarizes the actions or inactions of the agency which resulted in noncompliance. It may also include the extent of the deficient practice.

 

3rd component – Relevant Evidence or Findings

Relevant evidence or findings are the evidence collected by the surveyor to demonstrate lack of compliance. Findings are the result of interviews, record reviews and observations.

 

There may also be a 4th component if the agency is accredited. The accrediting body standard may also be addressed in the deficiency (e.g. HIII.10e – effective February 2009 the hospice is required to implement performance improvement projects based upon patient and internal needs and to document the projects and measurable progress achieved on the projects).

 

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The process of developing a plan of correction may include developing policies and procedures to remedy deficient practices promptly and ensure that the corrections are lasting. The agency must first analyze the deficient practice to determine what happened and why the problem or practice occurred.

 

Deficient Practices Typically Occur Because of System Failures or Discrete Failures

 

When a failure involves significant or many items within a system, then it is a system failure. The system itself may be absent, or facets of an existing system may be absent. For example:

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     "Plan of care developed after the various assessments were completed was not updated as patients’ conditions changed in 6 of 10 (60%) of the records"

 

The problem could be systemic if the agency has no policy on care plan updates or if the staff didn’t understand they were responsible for this action.

 

Discrete failures can be more difficult to identify. They are often found within a system but are more isolated, involving just one, or a limited number of individuals, staff, or may be present at one or a limited time or number of places.

 

The type of corrective action and monitoring plan can be developed once the type of failure is determined.

 

With an array of deficiency-related corrective actions and significant experience with successfully submitted plans of correction and monitoring plans, let Hospice Advantage Solutions draft your plan of correction. All plans of correction are reviewed by you prior to submission. In the rare instance that a revision is needed to your POC after submission, the revision will be completed at no cost to you.