Outpatient Facility Coding Alert

Ace Your Plan of Correction with 4 Simple Steps

If you read about survey strategies in our April newsletter, you’re well prepared for when the surveyor comes knocking. But if not, you may have ended up with some deficiencies. Surveys will always come as a surprise—after all, they’re required to be unannounced. And because guidance for surveyors is very general (they’re called “Interpretive Guidelines” for a reason), even the most well prepared facility could be caught off guard.

“There’s this nebulous cloud that hangs above us and it’s anyone’s best guess as to what surveyors are looking for,” says Judy Harless, MBA, CASC, who spoke to ASCA 2017 attendees about what to do when surveyors come calling. If that’s the case, you may have received a statement of deficiencies (Form CMS-2567) to alert you of non-compliance in your facility, along with your survey report. Here’s a quick rundown on what you might see on that letter:

• Standard Level Deficiencies: These indicate non-compliance with either a single requirement, or multiple requirements within a single standard. It doesn’t negatively impact your center’s ability to provide proper patient care, and doesn’t affect the health and safety of your patients.
• Condition Level Deficiencies: This one is serious. It indicates noncompliance with (a) requirements within a single standard, or (b) several standards within a condition. They represent a definite health or safety concern, and have a 90-day termination track. If you don’t correct them, your ability to collect Medicare payments is at risk.

Like any good ASC administrator, you’re probably eager to correct any deficiencies, even minor ones. Here’s where the real work begins. Unfortunately, Form CMS-2567 simply describes the evidence of any deficiencies, not the cause. “To say that [CMS] is vague is an understatement,” Harless points out. It’s up to you to do the digging necessary to uncover and address the root causes, and inform CMS of your plan of correction—your PoC. And time is not on your side. You must provide that PoC to your state survey agency within 10 calendar days of receiving the statement. Time to get started.

Step 1: First Things First

Your statement of deficiencies was accompanied by a cover letter. Read it. Then read it again, emphasizes Jan Allison, RN, CHSP, who spoke to ASCA attendees about coping with a survey’s aftermath. The cover letter contains several key pieces of information you need to thoroughly understand, like:

• The “due date” for your PoC (10 calendar days from the date your center received the letter)
• Submission instructions (names, addresses, contact information, and acceptable delivery methods)
• The types of deficiencies
• What needs to be addressed in the PoC
• How to document your PoC
• The date by which all corrections must be completed.

It’s also important to read the cover letter because there are few hard and fast rules. State requirements, survey processes, and surveyors vary. Your cover letter will note your specific requirements — they aren’t necessarily something you can look up online.

Watch out: Your surveyor may conduct a “revisit.” Revisits are performed when condition level deficiencies were noted, and are intended to verify correction of those deficiencies.

Step 2: Form CMS-2567

Form CMS-2567 is the basis for your PoC. It is also a public record of your survey. Since your PoC describes how you plan to correct the deficiencies listed in CMS-2567, it’s essential to completely understand this form as well. “Deficiencies have three components,” notes Allison. “A regulatory reference, a deficient practice statement, and relevant findings or evidence.” Each component is listed on the form:

• The regulatory reference precedes each listed deficiency and helps you locate the specific regulation in Appendix L of the CMS State Operations Manual (remember those Interpretive Guidelines?). The regulatory reference will usually begin with a Q or a K.

Example: Q-0061 §416.42(a) Standard: Anesthetic Risk and Evaluation

• For each deficiency cited, CMS-2567 will note what the standard is, and how it was not met.

Example: The physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The standard was not met based on observation and interview. The ASC failed to ensure that each patient was examined by the physicians immediately prior to surgery.

• Form CMS-2567 will also describe the surveyor’s documented reasons for noncompliance. It will describe the actions taken or not taken, and the extent of those actions.

Example: ASC leadership was not able to demonstrate how they assure a consistent approach in the assessment of patients. During a patient record review and subsequent interview, it was determined that the RN circulator examined the patient in absence of the physician on at least two occasions.

Step 3: PoC Like a Pro

The PoC you submit is a statement of how your center plans to correct all deficiencies listed in on CMS-2567. Because these corrections will be verified, it’s important “to not submit a PoC that is not feasible for [your] facility to accomplish,” advises Allison. Additionally, avoid “band-aid” solutions. “Determine what happened and » » why the problem exists or occurred,” says Allison. “If the cause of the failure isn’t identified, the center likely will not succeed in correcting it.” It could also likely recur.

Don’t forget: You must respond to each finding or instance listed on the form — not just each group of findings. For example, if your form showed three findings violating guideline Q241 (sanitary environment), you’d need to draft three individual responses, not just one response for Q241 in general. Although some states may designate another form to use, or refer you to a website, in most cases you’ll insert your PoC on the same CMS-2567 form.

Besides the actions your center will take to correct each deficiency, there are other criteria that need to be addressed in the PoC. Again, this information may vary so be sure to refer to your cover letter. For best chances of State approval, Allison recommends that your PoC includes at these seven elements (plus any others your cover letter requires):

1. The specific action you’ll take to correct the deficiency. Begin each with its corresponding regulatory reference tag (i.e., Q241).
2. A description of how those actions will improve the processes that contributed to the deficiency.
3. The procedure you’ll use to implement the corrections (basically 1 and 2 in more detail).
4. A specific completion date for each correction. Future plans aren’t allowed.
5. A description of monitoring or tracking procedures you’ll put in place to ensure your facility will stay in compliance.
6. The title of the person responsible for implementing the PoC (don’t list their name).
7. The administrator’s signature and date (on page 1 of CMS-2567).

Tip: Need extra space? Download and print an official continuation page at www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2567.pdf.

When you’ve completed the PoC, make a copy for your records. Submit the original, along with any supporting documentation required, according to the instructions on the cover letter. Supporting documentation, document attachments, or reference to attachments in the PoC is state and even sometimes surveyor-specific, warns Allison. If you have questions, don’t hesitate to contact your regional CMS office.

Step 4: What’s Next

What happens after you’ve submitted the PoC? Again, that will vary, says Allison. In some states, you’ll receive some form of written communication (an email or letter) stating that your PoC is acceptable. In other states, no news really is good news — you’ll only hear back if It’s not acceptable. Remember, if you responded to condition-level deficiencies, you can expect a revisit survey. Be prepared.

 

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