Nursing homes have mere days to respond to CMS 2567 surveys which identify deficiencies in regulated facilities. Penalties and Medicare reimbursements are on the line. An effective, timely response requires close collaboration between clinical, compliance, and management groups. This article explains three steps that can improve the quality and speed of your CMS 2567 survey plan of correction process.
The first step needs to be completed before your next inspection survey. You need a system to keep the survey and all related documents and data in one place. To design that system, you need to think about the surveys as more than a document with a list of deficiencies.
The better way to think about CMS 2567 surveys is to see them as a collection of documents and data about a particular nursing facility. The data on the CMS 2567 provides the basic structure for the collection, but it is just the start.
Each deficiency is its own record. Deficiencies can involve different teams, different documents, and different processes. This complexity means that each deficiency needs to be managed in isolation without losing its connection to the survey period.
Surveys also contain additional documents. For example, you might want to store correspondence related to the survey, or your own internal memorandum related to the survey, or images of the facility. Those documents help you respond to the survey but are not obviously part of the survey. It is important to keep those documents readily available for those working on the survey.
The system for managing CMS 2567 surveys needs to bring all the relevant team members on board. Clinical staff are critical to the substance of the plan of correction and assessment of the deficiency. Compliance and legal team members need to ensure that the response is both necessary and sufficient without compromising the rights of the organization. Management and operations staff need to understand what changes are required to develop an implementation plan.
Once the team is onboard, you can assign responsibilities and tasks to individual members. If your system for managing the CMS 2567 survey response treats each deficiency separately, then you can sign task at a granular level based on specific deficiencies. This is the most efficient use of your internal expertise because you assign work to those who are most knowledgeable about that particular issue.
One of the best ways to improve the quality, consistency, and speed of drafting plans of correction is to harvest your prior plans which addressed similar deficiencies. Your CMS 2567 survey response system should contain a library of plans of correction that you can reuse and adapt to new deficiencies.
This library is particularly effective when responding to state inspection deficiencies which are similar to Federal deficiency plans of correction you have drafted in the past.
A POC library also means that you can review all of your plans of correction in one place and easily push changes and updates to staff using your response software.
Once you have created a CMS 2567 survey response solution that treats each survey as a collection of documents and data, provides a collaboration platform, and gives access to prior plans of correction, then you are ready to respond quickly to a new survey inspection.
When a survey identifies a large number of deficiencies, the pressure to respond in a few days is intense. That pressure is compounded when some of the deficiencies have scope and severity scores which are serious.
It is also important that the team collaborate on the substance of the plan of correction.
Designate a lead person to coordinate the response. Everyone on the team should know who the responsible person is so questions get funneled to the right person.
Naming one person as the survey response coordinator does not mean that only one person is responsible for all of the plans of correction.
It is critical that you parcel out the responses to the right people, impose task deadlines, and monitor task completion. When you treat each deficiency as a single item, it becomes easy to assign the POC or background research to individual people.
Not all tasks need to relate to a single deficiency. For example, you might assign a task to your General Counsel to review and comment on the survey holistically.
On the other hand, if you need someone in IT to review the security of the patient records because of a particular F-Tag deficiency you can assign that task to that person.
In short, each deficiency generates simple tasks and each task gets assigned to the right person.
With CMS 2567 surveys the clock is ticking. Since all of the data, documents, and tasks are in one location associated with the survey, you can monitor all of the activity easily.
When you are managing a survey response, the number of days remaining to complete the the the plans of correction should be clear.
Your task tracking system should show you open, accepted, completed, and canceled tasks. You should also be able to see who did which tasks on what days.
A well-designed CMS 2567 survey response system and process allows you to monitor the status of individual plans of correction related to particular deficiencies. The status will show with the survey details as well as in reporting tools that give you insight to task status.
Penalties and fines associated with poorly managed plans of correction impose direct natural consequences for your organization. However, the indirect costs might outweigh those direct penalties. The caliber and timeliness of your response is a few clicks away from your patients and their families. Effective CMS 2667 survey responses for nursing homes is not only legally required; it is good business practice.