Inspection Process: Writing a Plan of Correction
A plan of correction (POC) is required for every WAC violation noted in a Statement of Deficiencies (SOD) report. WAC 388-78A-3152 states that, by signing the attestation of correction statement beneath each citation in the SOD, the assisted living representative is indicating that the deficiency is or will be corrected and the date by which the correction will be completed. The SOD, with the signed and dated attestations, must be returned to the Department within 10 calendar days of receiving the report.
While the POC for each deficiency is not sent to DSHS, it must be filed with a copy of the signed SOD on the assisted living facility premises and shared with licensors or complaint investigators upon request. Residents also have the right to review the facility’s POC.
In writing a POC, it is important to grasp the intent of the citation, so the correction is targeted and effective. Read and re-read the citation to determine what the specific failed practice is prior to developing the POC. Then, working with other pertinent staff members in the facility, devise a workable POC that includes the following six parts:
- HOW THE HOME WILL CORRECT THE ISSUE FOR EACH RESIDENT LISTED IN THE CITATION. This demonstrates that the facility took action to address specific resident issues identified by DSHS staff. List each resident by number in this part of the POC, and state how the facility corrected the issue for that resident. If no resident was listed in the citation, state this. If a resident was listed in the SOD but no longer lives in the assisted living, state this.
- HOW THE HOME WILL PROTECT OTHER RESIDENTS IN SIMILAR SITUATIONS. This part prompts you to look beyond the residents listed in the citation, to others who might fall into the same category. Completing this part of the POC allows you to see if systems are broken and lays the groundwork to fix that system and effectively minimize the likelihood of a re-citation on the same issue.
- MEASURES THE HOME WILL TAKE OR SYSTEMS IT WILL CHANGE TO ENSURE THE PROBLEM DOES NOT RECUR. This is a proactive measure that encourages an honest look at how systems are operationalized in the building and by the company. Leadership must be willing and able to change and adapt new programmatic measures to fix the core issue(s) that led to the citation.
- HOW THE HOME PLANS TO MONITOR ITS ONGOING PERFORMANCE TO SUSTAIN COMPLIANCE. Beyond planning, this component of the POC prompts a futuristic focus on maintaining the new system or method. This might include data collection and analysis and/or scheduled look-in steps to determine staff’s compliance with the updated system.
- DATE THE CORRECTIVE ACTION WILL BE COMPLETED. The citation must be corrected within 45 days from the last date of inspection, or sooner depending on the severity of the situation. If an administrator needs additional time, the DSHS field manager must be consulted, and the extension approved.
- NAME AND TITLE OF THE PERSON RESPONSIBLE FOR THE CORRECTION. This person should have the ability to make changes and be responsible to oversee the system’s operation.
The POC may require updating, based on the outcome measures put in place to correct the issue. If updates or complete re-writes are necessary, document as such and file with the original POC.
If you have questions related to assisted living regulations, processes, training, or nursing, contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
Posted in Assisted Living, Survey & Regulatory