When Your ASC Needs "Immediate Corrective Action": How to Form a Plan of Correction for Medicare

The following article was written by Chris McMenemy, vice president of Ortmann Healthcare Consultants.

So Medicare paid you a surprise visit and the result, unfortunately, was a Plan of Correction. Although you most likely are feeling a great deal of panic, take a few deep breaths and get busy. You and your ASC can survive the process, and maybe you’ll be a little bit better in the end.

First of all, don't beat yourself up. You are not alone — not the first and not the last to be told to take immediate corrective action. With some hard work and important self-examination, you will be able to write an acceptable plan that will keep your ASC in business.

Medicare inspections are always unannounced. The only way to be truly prepared is to always be prepared. That means you must be up-to-date on all Medicare regulations. One great help that I've found is to read the Interpretative Guidelines that are used by Medicare to train surveyors. This document gives much more detail than the federal regulations and is a great tool for surveyor readiness.

What is a Plan of Correction?
So what is a Plan of Correction? It is a document that lists any problems (deficiencies) the surveyor finds in the way the ASC is operated. And panic is an understandable emotion, as the ASC has 10 days (counting weekend days) to respond to the POC with a plan to correct the deficient practices or risk losing Medicare certification. The more problems that are noted by the surveyor, the more work will be required in writing the Plan.

If the POC is not received back within 10 days, steps will be taken by Medicare to terminate your certification. And although you may appeal the POC's findings, you are not entitled to a hearing prior to termination, so it may be quite some time before you would be able to bill for Medicare patients as the hearing process progresses. It's also important that you write and implement a good plan because the surveyors will re-survey your ASC, and they will expect that the deficiencies have been satisfactorily corrected. If not, your center could still lose its certification. Serious business? You bet!

During the survey, don't be afraid to ask questions. Make sure you understand exactly how the surveyor believes a regulation is not being met. That information is invaluable when it comes time to respond to the plan. You will also receive more information once the actual Plan is received, but speaking directly to the surveyor is always helpful. Often during a discussion, the surveyor will understand better your process and in the end not mark a deficiency on a particular item.

How to Respond to the Plan of Correction
Once you receive the plan, you most likely will feel overwhelmed, but break it down into individual pieces and get busy! This is a "drop everything" time for a few people in your ASC. You must put sufficient time and effort into this response; that may mean canceling a few procedures or bringing in extra staff so that others can dedicate their time to the response.

For each citation, you need to respond to five components. When I have assisted with writing a POC, I actually number each component and use an outline form in the response for multi-answer components: 1 a. 1 b. 1c., etc. Briefly, the components require the response to:

1) Identify how corrective items were accomplished for any patients who were affected by the deficiency;
2) Describe how the corrections will protect patients in the future;
3) Describe the measures that will be put in place to ensure the deficiency will not re-occur;
4) Identify how the ASC will monitor its correction to ensure the solutions are sustained and do not reoccur; and
5) State the date the corrective action will be completed.

Components 3 and 4 are important as in answering those items, you have the crux of the plan. For instance, if the Plan stated that the ASC failed to ensure each patient had a pre-surgical assessment completed that included an examination for any changes in the patient's condition since their most recent H&P, numbers 3 and 4 might read as follows.

3) The following actions will be taken to ensure the deficient practice will not re-occur:

a) Policy #10017 History & Physical has been updated to include the need for documentation that the H&P is to be reviewed for all procedures during the pre-surgical assessment
b) Provider & staff training will take place to ensure all are aware of the H&P update requirements
c) The patient chart record has been updated for easier documentation and physicians will receive training on the use of the updated record.

4) The Center Director is responsible for ensuring this correction is achieved and sustained. The following will be utilized:

a) Policy #10017 History & Physical will be presented for discussion and approval to the Quality Committee and Governing Board.
b) The revised patient chart record will be presented for discussion and approval to the Quality Committee and Governing Board.
c) All patient charts will be reviewed for compliance with this standard for a period of three months. Results will be reported to the Quality Committee.

Respond to each deficiency with an answer for each required component with specific information and the plan will be completed. Then, make sure you have done everything that you said you would do. I usually include changes to policies and forms in the POC as attachments to the plan. Make a checklist of all documents and training that need to be completed to assist in keeping track of everything that is to be completed.

Although you may not be happy to have a Plan of Correction in your life, it is something that with hard work, you can complete. The discussions that will take place with your staff and physicians can actually be beneficial to the ASC as a whole. I hope you never need to complete a POC for your ASC, but if you find yourself faced with a Plan, don't panic: Roll up your sleeves and get to work, and keep your Medicare certification in tact. It’s worth it in the long run.

Learn more about Ortmann Healthcare Consultants.

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