CMS Issues Updated Guidance to Surveyors on Plan of Correction Reviews and Revisits

(June 13, 2024) On June 6, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a memo that clarified expectations regarding Plans of Correction (POCs) and facility revisits. They are reminding state survey agencies that POCs “are an element of the compliance review”; however, they are ultimately no more than an allegation of compliance and signal the facility's readiness for revisit.

When non-compliance is cited at a level requiring a mandatory onsite revisit to verify correction and compliance, CMS and/or the state survey agency will obtain a POC. Revisits are required when a survey finds substandard quality of care, harm, or immediate jeopardy. The findings identified during the subsequent onsite revisit survey will then verify either compliance or continuing non-compliance with the regulatory requirements. Therefore, CMS and states prioritize the revisit survey as the primary means of assessing compliance following receipt, review, and approval of the POC.

If CMS and/or the state are unable to approve a POC after two submissions, they are instructed to reach out to the facility to request a revisit and then perform a revisit survey, per existing CMS policy and guidance. The date of compliance will be the POC completion dates indicated on the most recent POC submitted as verified during the onsite revisit.

The guidance does not apply to the following:

• The Plan of Removal process for Immediate Jeopardies identified in Appendix Q of the State Operations Manual (SOM);
• Providers who have been imposed a Directed Plan of Correction as an enforcement remedy;
• Surveys with deficiencies that only require a desk review to determine compliance through review of a POC (i.e., offsite audits) as outlined in SOM Chapter 7, Section 7317.2;
• Initial certification process;
• Other surveys with findings that do not require an onsite revisit;
• Life Safety Code Temporary Waiver requests; and
• Other circumstances that CMS or the state agency believe, following CMS location review and recommendation, warrant additional POC submissions (as approved by CMS Divisional leadership).

Members should note that CMS has a new Quality in Focus interactive video series. The series of 10–15-minute videos are tailored to provider types and aim to reduce the deficiencies most commonly cited during the CMS survey process, like infection control and accident prevention. See the Quality, Safety, and Education Portal Training Catalog, and select Quality in Focus.

Please reach out to your CMS Regional Office with inquiries regarding the memo. Members may also find these LeadingAge National resources helpful in writing and implementing effective POCs.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147