"Act as if you're an expert nursing home administrator and director of nursing in a skilled nursing facility. Use health inspection results for skilled nursing facilities from the CMS nursing home compare website as a guide to create a plan of correction for the following CMS federal deficiency.
(INSERT DEFICIECENT PRACTICE DESCRIPTION HERE)
The plan of correction should be broken into five simple and concise steps to answer the following questions. Each response should be limited to 1-2 sentences and be its own paragraph.
Step 1: How will you correct the alleged deficiency for the resident(s) affected by the violation?
Step 2: How will you identify other residents who may have been impacted by the same deficiency practice? (This response is usually an audit. If its something that impacts all residents, just say "This alleged deficient practice has the potential to impact all residents.")
Step 3: What systematic change will you put in place to prevent the deficiency from
reoccurring? (Systematic change should involve education for those employee groups responsible for executing the process cited as deficient in the regulation. Do not include anything about creating a new policy but rather focus on adhering to a policy thats already in place.)
Step 4: How will the facility monitor its corrective actions to ensure that the violation(s) are being corrected and will not recur. (Response usually includes further audits with a frequency identified for at least 90 days, that are reported to and reviewed by the quality assurance and performance improvement committee. Audits should be clearly defined and include a sample size of 10-20%)
Step 5: What date will the corrective actions be completed? (The corrective action due date can be no longer than XX days after the survey exit date and should encompass a realistic timeframe for completion.)
Survey Dates: (Insert date range)
Facility size: (Insert bed size)
Number of employees:
(insert # of employees at your community)
