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Tips for Creating an Acceptable Plan of Correction by Jennifer Windram, RN


checklist.jpgThe following elements are required for an acceptable plan of correction:


  1. A statement as to why the deficiency occurred and the plan to correct the deficiency.

  2. The procedure for implementing the plan of correction.

  3. The monitoring process to ensure the plan of correction is effective.

  4. The title of the person responsible for implementing the plan of correction.

  5. The date of completion for the plan of correction.


Seems simple enough. However, many agencies have their plan of correction (PoC) rejected multiple times. This is not only frustrating, but it’s also time consuming. Here are a few tips to keep in mind when creating a PoC:


1. Always begin by focusing on why the deficiency occurred. What systems were lacking or incomplete? Was there something we should have been doing, but weren’t? Is this related to a knowledge deficit? Honing in on the reason the deficiency occurred will make it easier to address the remaining elements of the PoC and it will increase the likelihood that your plan is successful today and moving forward.


2. Be sure to thoroughly read every example in a long deficiency citation. Multiple issues can be written under the citation for one tag. For example, under a clinical records tag, an agency might be cited for improper corrections or addendums to a record, conflicting or inaccurate information and missing forms or documents. All of these issues are related to clinical records; however each issue will require it’s own corrective actions.


3. Remember to think systemically. For example:


-If your agency is cited for a CNA performing duties outside of their scope of practice, you will want to address the issue with the CNA named in the deficiency AND evaluate all the care provided by ALL of your CNAs to determine if this issue is occurring with other patients/clients. You will also want to evaluate your agency’s processes for initial training and ongoing supervision.


-A patient has a negative outcome after a nurse, who was not deemed competent to perform tracheostomy care, suctioned the patient incorrectly. You will want to address tracheostomy care with this nurse, ALL of your other nurses, AND then look at the other tasks your nurses are performing to evaluate whether they have been deemed competent with these tasks as well. You will also want to evaluate and refine your initial training/competency program to ensure it is comprehensive and addresses all the tasks/skills your nurses perform as part of their regular job duties.


Keep these tips in mind and you’ll increase the likelihood that your plan of correction is accepted on its first submission!


Did you recently have a survey with CDPHE? Would you like assistance formulating a plan of correction that not only conforms to CDPHE’s standards, but also suits your agency? CHCTC can help!


CHCTC will work with you and your agency to:


-Review the deficiency list and hone in on the key areas that must be addressed

-Evaluate your current systems to identify the processes that can be modified or processes that need to be created

-Write a compliant plan of correction (PoC) that includes all five required elements

-Create a list of action items that must be completed as evidence of implementation of the PoC


SPRING SPECIAL with Jennifer Windram - Now until June 30, 2014!



  • Up to 5 deficiencies: $85/deficiency

  • 6-10 deficiencies: $82/deficiency

  • 11-15 deficiencies: $79/deficiency

  • 16+ deficiencies: $76/deficiency



Included with the Spring Special:

-An initial onsite consultative visit (limited to the Denver Metro Area) to evaluate your agency’s systems, policies and procedures and develop an action plan. Up to 1.5 hours.

-Up to 2 hours of telephonic or email communications to discuss the plan of correction.

-Revision of the plan of correction if not accepted by CDPHE

-Discounted consultative services at a rate of $85/hour to assist with identified action items for a period of 3 months following the first visit. Discounted from the standard rate of $120/hour.


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