CMS Issues New Guidance for the Formatting of the Plans of Correction

PUBLISHED: Jul 6, 2017
Relevant to: Critical Access Hospitals, Hospitals, Long Term Care

Format for Plans of Corrections (PoCs)/Allegations of Compliance (AOC):

Providers/Suppliers and Clinical Laboratory Improvement Amendments (CLIA) Laboratories will no longer be required to write their PoC (for CLIA, this includes AOCs) on the right side of the CMS Form 2567. Providers/Suppliers or CLIA Laboratories may submit their PoC/AOC as a separate document attachment or may continue to document the PoC on the right side of the CMS Form 2567.

Signature on First Page:

The Laboratory Director or Provider/Supplier Representative’s signature is still required on the first page of the CMS Form 2567 for the PoC/AOC. The PoC/AOC can be sent as an attachment to the signed first page of the CMS Form 2567.

According to Section 2728B - Plans of Corrections (POC) of the State Operations Manual (SOM), the following are required elements, no matter the format, for an approved Plan of Correction:

  • The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited.
  • The procedure for implementing the acceptable plan of correction for the specific deficiency cited.
  • The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements.
  • The title of the person responsible for implementing the acceptable plan of correction.

The CMS Form 2567 and accompanying PoC or Allegations of Compliance (AOC) are publically releasable documents, so providers are required to omit any Privacy Act or Protected Health Information. If such information is included, the State Survey Agency will notify the Provider/Supplier or CLIA Laboratory and obtain an amended POC.

Under 42 CFR §483.10(g) Examination of Survey Results, Long-Term Care (LTC) facilities are required to post the most recent CMS Form 2567 and any PoC in effect. LTC facilities choosing to attach their PoC to the first page of the CMS Form 2567 are required to post the PoC with the publically available CMS Form 2567.

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