Source: https://www.dads.state.tx.us/business/CBT/correctionplans-icfiid/SC_WIP45.html
Timestamp: 2017-07-28 02:53:28
Document Index: 708955631

Matched Legal Cases: ['art 1', 'art 2', 'art 1', 'art 2', 'art 3', 'art 1', 'art 2', 'art 3', 'art 4']

Writing Acceptable Plans of Correction for Intermediate Care Facilities for
Individuals with an Intellectual Disability or Related Conditions (ICFs/IID)
Section Two: The Provider and the Regulatory Process
CMS-2567 and the DADS-3724
Structure of a Violation and Deficiency
1st Component - The Regulatory Reference
Regulatory Reference Categories
2nd Component - The Deficient Practice Statement
3rd Component - The Relevant Finding
Examples of Relevant Findings
Construction of a Violation/Deficiency Example
System or Discrete Failure?
Example of a System Failure
Example of Discrete Failure
Section Three: Developing an Acceptable Plan of Correction
Element 1 - Identified Individuals Affected
Element 1 - Deficiencies that DO NOT Include Identifiers
Element 1 - Deficiencies That Include More Than One Example of Relevant Findings
Address EACH Instance of Noncompliance and ALL Evidence!
Element 2 - Identify Others Who May Be Affected
Element 2 - Example
Element 3 - Changes to Prevent Recurrence
Element 3 - Example of a System Facilities Can Put Into Place
Element 4 - Monitoring of Corrective Actions
Element 4 - Example of a Monitoring System a Facility May Establish
Element 5 - Date of Completion
Element 5 - "Reasonable" Date of Completion
Monitoring, Achieving and Maintaining Compliance
All Parts of the PoC Must be Acceptable
Example of an Unacceptable PoC
Deficiency Summary - Example Part 1
Deficiency Summary - Example Part 2
Proposed PoC Unacceptable Example - Part 1
Proposed PoC Unacceptable Example - Part 2
What Makes This PoC Unacceptable?
Example of an Acceptable PoC
Deficiency Summary - Example Part 3
Proposed PoC Acceptable Example - Part 1
Proposed PoC Acceptable Example - Part 2
Proposed PoC Acceptable Example - Part 3
Proposed PoC Acceptable Example - Part 4
What Makes This PoC Acceptable?
Section Four: PoC Submission and On-site Revisits
If the PoC is NOT Acceptable
Other Plan of Correction Issues and Reiteration
Other Plan of Correction Issues and Reiteration Cont'd
On-site Follow-up Revisits
The PoC as a Management Tool
A general statement indicating that compliance has been achieved or will be achieved is not acceptable. The PoC must identify the nature of the corrective action (i.e., how the corrective action will address the concerns identified in the CMS-2567 or DADS-3724).
The PoC must identify what systematic changes will be made to ensure that the deficient practice will not recur and how the facility will monitor its corrective action to ensure that the deficient practice remains corrected (i.e., what quality assurance program will be put into place).
Date last modified: October 20, 2016.