Transcript Tennessee Department of Health

Tennessee Department of
Health
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TIPS FOR
SUBMISSION OF
AN ACCEPTABLE
AOC/POC
AoC/PoC TIPS
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AoC/PoC Review
 When Immediate Jeopardy is
identified, you may submit an
Acceptable Allegation of Compliance
(AoC) or;
 To obtain complete substantial
compliance you may submit an
Acceptable Plan of Correction (PoC)
AoC/PoC TIPS
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AoC/PoC Review
IN CASES OF IMMEDIATE JEOPARDY
 Facility may submit an allegation of removal
of the IJ (AoC)
 CMS & HCF will review the AoC to
determine if acceptable
 AoC must include: date the IJ was removed
and sufficient detail to demonstrate that the
IJ has been addressed.
AoC/PoC TIPS
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AoC/PoC Review
Sufficient Detail
 What corrective action(s) will be accomplished for
those residents affected by the Immediate Jeopardy
practice.
 How you will identify other residents that may have
the potential to be affected by this Immediate
Jeopardy practice and what corrective actions will
you take for those residents.
AoC/PoC TIPS
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AoC/PoC Review
Sufficient Detail
 What measures will be put into place or what
systematic changes you will make to ensure that IJ
will not recur.
 How the corrective action(s) will be monitored to
ensure the IJ will not recur.
 What quality assurance program will be put into
place including who will monitor and how often.
AoC/PoC TIPS
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 Not
a forum for the dispute of
deficiencies {use IDR for this process}
 Do not use statements with disclaimers
such as “this AoC/PoC is inadmissible
by any third party in a civil or criminal
action” {The AoC/PoC becomes public
record as recorded on the CMS 2567}
AoC/PoC TIPS
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A completion date may not be
earlier than the date of the
deficient practice or earlier than
the exit date of the survey unless
the deficient practice was
corrected while the survey was
in progress.
 You must place a completion date that you will
have a specific deficient practice corrected. This
date goes in the right hand column directly across
from where you begin the AoC/PoC for each F tag
number. Remember if Immediate Jeopardy, your
completion date must be within the 23 day date for
termination. You must also give at least two days
prior to the 23rd day so that a revisit can occur.
Should you wait until two days prior to the 23rd day
and the revisit finds that your deficiencies are not
corrected, then it is to late to resubmit an AoC and
your facility will go into termination. It is best to
have completion dates as early as possible so that
a second revisit can occur if needed
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AoC/PoC TIPS
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 If you are addressing a second or third submission of an
AoC/PoC make sure you have addressed all the
discrepancies found in your previous AoCs/PoCs.
 Make sure you edit your AoC/PoC in order not to leave
any uncompleted sentences. Also be sure that your PoC
can be read and understood by a lay person.
 When submitting a corrective action plan for deficiencies
cited, you must designate whether the document is an
AoC or PoC.
With Immediate Jeopardy deficiencies, you must
submit a copy of your AoC or PoC to both the
Regional Office of Health Care Facilities and to CMS
Region IV Office in Atlanta.
Address your cover letter with your AoC/PoC to:
Faye Vance, Regional Administrator
ETRO
Debra Verna, Regional Administrator
MTRO
Shirley Jones, Regional Administrator
WTRO
Karen Powell, Enforcement Officer, CMS Region IV
The addresses will be on your enforcement letters.
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AoC/PoC TIPS
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 If you are auditing a process as part of your AoC/PoC
explain what tool you will use for this audit and
include a copy of the tool with your AoC/PoC .
 If you include with your AoC/PoC a table of contents
then make sure that all the contents listed are found
in the AoC/PoC or it’s attachments.
 When conducting in-services for employees you
must address how absent and future employees will
receive this training.
AoC/PoC TIPS
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 If you make changes or write new
policies/procedures please provide
copies as an attachment to your
AoC/PoC.
 If you establish a new training program
such as for an Alzheimer’s program
then you must submit with the
AoC/PoC a copy of the curriculum.
AoC/PoC TIPS
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 If you start a new communication
program such as a 24 hour report,
walking rounds, stand up reports etc.,
you must explain how this new report is
utilized as well as submit a copy of the
policy for the implementation of the
report.
AoC/PoC TIPS
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 If in your AoC/PoC you state that an audit is
conducted, you must state who conducted
the audit (by title), dates of the audit (fromto), findings of the audit, and actions taken
as a result of the audit.
 All in-services listed in your AoC/PoC must
have content described, date conducted,
position of person conducting, and
disciplines of staff that attended.
AoC/PoC TIPS
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 If your AoC/PoC lists monitoring, then
much detail of the monitoring is
required, such as who (by title) will
monitor, the issues being monitored in
detail, the frequency of monitoring as
well as the effectiveness found by the
monitoring.
AoC/PoC TIPS
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 If your AoC/PoC
states that you
changed a policy such as a nursing
policy
on
charting
frequencies,
monitoring of that policy must be done
to assure it has been audited for
compliance.
AoC/PoC TIPS
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 Do not generalize titles. It is not sufficient
to say staff. You must be more specific such
as licensed staff, supervisor staff, certified
nursing assistants etc.
 If you address committees in your AoC/PoC
then you should be clear and identify (by
title) the members of the committee .
AoC/PoC TIPS
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 Do not use words like non drug intervention,
new therapy provider etc. You must explain
in detail and be specific such as: group
therapy was performed by a Licensed
Clinical Psychologist, Medical Director,
Director of Nurses etc.
 You must address each resident identified in
each deficiency.
AoC/PoC TIPS
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 You may not cross reference in your AoC/PoC.
You may find that some of the deficiencies have the
same findings and you may find that the citations
may have cross references. The cross referencing
in citing deficiencies is legally allowed when
specific violations affect more than one citation.
The AoC/PoC has different requirements in that
the corrections must be detailed and specific to
each deficiency cited. If you cross reference in
your AoC/PoC it will result in an unacceptable
AoC/PoC.
IJ Deficiencies January –April 2008
Tags
# of Times Cited
 F-490 Administration
7
 F-281 Service of Prof. Stds
5
F-520 QA
5
F-319 Mental & Psychological function
3
 F-157 Notification of Changes,
3
F-250 Social Services
3
F-F-327 Hydration
3
IJ Deficiencies January –April 2008
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Tags
# of Times Cited
F-223 Abuse,
2
F-225 Report and Investigate incidents
2
F-226 Screen Emp. For Abuse, Neg. Missap. 2
F-279 Dev., review, revise care plans
2
F-280 Dev. Care plan after 7 days of Assess. 2
F-333 Significant Medication Errors
2
F-353 Sufficient Staff
2
F-501 Medical Dir.
2
F-502 Lab. Services
2
IJ Deficiencies January –April 2008
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Tags
# of Times Cited
F-224 Dev. & follow Abuse Policies
1
F-287 MDS Transmission
1
F-314 Pressure Sores
1
F-323 Accidents
1
F-325 Nutrition
1
F-332 Med. Errors >5%
1
F-428 Drug Reviews
1
F-441 Infection Control
1
F-495 CNA working over 4 Mo. Not Cert.
1
F-505 Laboratory Service
1