Form CMS-2567 response
Plan of Correction Worksheet
The five elements a plan of correction must address before you submit it to the state agency.
PLAN OF CORRECTION WORKSHEET Tag cited: [F___] Scope and severity: [___] Date of survey: [ ] Deficient practice as written on the CMS-2567: [ ] 1. HOW CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED [Resident-specific actions, dates completed, who verified] 2. HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE [Audit population, method, dates] 3. WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT RECUR [Policy revision, education, process change, equipment, staffing] 4. HOW THE FACILITY WILL MONITOR ITS CORRECTIVE ACTIONS Audit tool: [ ] Sample size: [ ] Frequency: [ ] Responsible: [ ] Results reported to the QAA committee: [FREQUENCY] 5. DATE THE CORRECTIVE ACTION WILL BE COMPLETED Completion date: [ ] Prepared by: [ ] Administrator signature: ____________ Date: ______