How to Handle a Plan of Correction (POC) After a Home Health Deficiency

When a home health agency receives a deficiency during a federal CMS survey or a state licensing survey, submitting a complete and compliant Plan of Correction (POC) is mandatory. A POC demonstrates the agency’s ability to identify issues, correct them, and implement long-term systemic improvements. State and federal regulators view the POC as evidence of whether an agency can sustain compliance with the Medicare Conditions of Participation (CoPs) and applicable state regulations.

This detailed guide outlines how to develop, write, and implement a strong POC after receiving deficiencies from CMS, CDPH, IDPH, HHSC, or any other state survey authority. All cited references include full URLs for clarity and regulatory accuracy.

What Triggers a Plan of Correction

A POC is required whenever a home health agency receives:

• A standard-level deficiency

• A condition-level deficiency

• A state-level Title 22, Administrative Code, or other state licensing violation

• A repeat deficiency

• A deficiency found during a revisit

• A deficiency discovered during a complaint investigation

The federal requirement for Plans of Correction is located in 42 CFR §488.28 – Plan of correction
https://www.ecfr.gov/current/title-42/section-488.28

State survey agencies operate under federal authority but may impose stricter deadlines or additional requirements.

Federal vs. State Requirements

Federal Requirements (CMS)

CMS outlines the process for addressing deficiencies in:

• State Operations Manual (SOM) Chapter 2
  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107_c02.pdf

• SOM Appendix B (Home Health Survey Protocol)
  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_b_hha.pdf

• 42 CFR Part 484 – Home Health Conditions of Participation
  https://www.ecfr.gov/current/title-42/part-484

CMS requires that all POCs:

1. Address each cited deficiency individually

2. Provide immediate correction actions

3. Implement systemic process changes

4. Include monitoring mechanisms

5. Identify responsible personnel

6. Include acceptable completion dates

7. Be submitted within 10 calendar days of receiving the CMS-2567

CMS does not allow excuses, disagreement with findings, or statements that the deficiency was an isolated event.

State Requirements

Each state may have additional or stricter requirements.

Examples:

California Department of Public Health (CDPH)
Title 22 Licensing Enforcement
https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/HHA.aspx

Illinois Department of Public Health (IDPH)
Home Health, Home Services, and Home Nursing Agencies
https://dph.illinois.gov/topics-services/health-care-regulation/home-health-agencies.html

Texas Health and Human Services (HHSC)
Home Health Agency Licensing Standards
https://www.hhs.texas.gov/providers/long-term-care-providers/home-health-agencies

Some state agencies require additional documentation such as:

• Evidence of staff retraining

• Copies of revised policies

• Proof of implementation before approval

• State-specific corrective action forms

When federal and state requirements differ, an agency must comply with the stricter standard.

Required Structure of a Plan of Correction

CMS mandates that each POC follow the structure defined in 42 CFR §488.28
https://www.ecfr.gov/current/title-42/section-488.28

Every citation on the CMS-2567 must contain the following:

1. Corrective Action for the Affected Patients

Describe the specific actions taken immediately to correct the problem for the patient(s) referenced in the deficiency.

Examples:

• Physician notification

• Revision to the plan of care

• Completing missed documentation

• Conducting a medication reconciliation

• Updating orders or care instructions

Immediate correction must occur before submitting the POC.

2. Corrective Action for All Patients with Potential to Be Affected

This demonstrates that the problem is being addressed system-wide.

Examples:

• Chart audits for all patients receiving similar services

• Reviewing all patients under specific clinicians or service lines

• Performing an agency-wide assessment of similar processes

CMS expects a clear explanation of how broad the issue may be and how the agency will identify all potentially affected individuals.

3. Systemic Changes to Prevent Recurrence

This is the most important section and must include:

• Revised or newly created policies

• Process redesign

• Updates to clinical workflows

• Additional supervisory oversight

• Strengthened communication protocols

• New documentation tools

• Implementation of checklists or standardized processes

• Updates to EMR templates

CMS expects agencies to address root causes, not just surface-level symptoms.

This aligns with the QAPI Condition of Participation at 42 CFR §484.65
https://www.ecfr.gov/current/title-42/section-484.65

4. Monitoring and Quality Assurance Plan

A monitoring plan must describe how the agency will ensure ongoing compliance.

A compliant monitoring plan must include:

• The type of audits to be conducted

• The sample size

• The audit frequency (weekly, monthly, quarterly)

• Responsible personnel (Administrator, DON, QAPI coordinator)

• Governing Body review process

• Actions that will be taken if non-compliance is found

CMS expects monitoring to last long enough to ensure sustained compliance.

5. Completion Date

The completion date must be:

• Reasonable

• Specific

• No more than 60 days from the survey date
  (in accordance with 42 CFR §488.28(d)
  https://www.ecfr.gov/current/title-42/section-488.28 )

Agencies must be able to demonstrate that all actions will be completed by the stated date.

Common Reasons POCs Are Rejected

Surveyors frequently reject POCs due to:

• Lack of detail

• Missing systemic corrections

• Missing monitoring plans

• Vague descriptions such as “staff were re-educated” without evidence

• Failure to identify root causes

• Lack of responsible personnel

• Overly long timelines

• Copy-and-paste responses

• No policy revision when a policy contributed to the deficiency

To avoid rejection, the POC must demonstrate that the agency understands the issue, fixed the issue, and implemented safeguards to prevent recurrence.

How to Write a Strong, Acceptable Plan of Correction

Step 1: Analyze the Deficiency Thoroughly

Review the CMS-2567 line-by-line and assess:

• Who was involved

• What process failed

• Why the deficiency occurred

• Whether the problem is isolated or systemic

CMS requires that agencies perform a structured root cause analysis, which aligns with QAPI expectations.

Step 2: Conduct Root Cause Analysis (RCA)

RCA methods include:

• The 5 Whys

• Fishbone (Ishikawa) Diagram

• Process Flow Mapping

• Staff interviews

• Review of clinical records and logs

A thorough RCA helps identify gaps in training, communication, documentation, policies, or workflow.

Step 3: Implement Immediate Corrective Actions

Immediate actions must occur before writing the POC.

Examples:

• Completing missing documentation

• Updating the plan of care

• Conducting a supervisory visit

• Re-educating the involved staff

• Notifying physicians or families

• Correcting scheduling errors

CMS expects proof of immediate action.

Step 4: Revise and Strengthen Policies

If a policy contributed to the deficiency, it must be updated.

Policies must align with:

• 42 CFR Part 484 Home Health CoPs
  https://www.ecfr.gov/current/title-42/part-484

• CMS State Operations Manual Appendix B
  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_b_hha.pdf

• State-specific licensing regulations

Surveyors often request copies of revised policies as part of the POC review.

Step 5: Provide Staff Education and Competency Verification

Agencies must document:

• Attendance sheets

• Training materials

• Competency validation forms

• Updated orientation materials

• Supervisory follow-up documentation

A single training session is not sufficient unless paired with ongoing monitoring.

Step 6: Develop a Long-Term Monitoring Plan

Monitoring plans should include:

• Weekly chart audits for the first 4–12 weeks

• Monthly monitoring for several months afterward

• Inclusion in QAPI meetings

• Reporting trends to the Governing Body

This demonstrates continuous quality oversight.

Step 7: Submit the Plan of Correction Within the Required Timeline

Federal rules require POC submission within 10 calendar days per
42 CFR §488.28(b)
https://www.ecfr.gov/current/title-42/section-488.28

States follow similar or identical timelines.

Failure to submit a timely POC may result in:

• Civil monetary penalties

• Directed plan of correction

• Directed in-service training

• Temporary management

• Termination from Medicare

Condition-Level Deficiencies

Condition-level citations require more extensive corrective actions and usually trigger:

• A mandatory revisit survey

• Additional documentation requests

• Possible enforcement remedies

• Review of QAPI, clinical records, HR files, and policies

CMS enforcement remedies are located at 42 CFR Part 488 Subpart A
https://www.ecfr.gov/current/title-42/subtitle-A/chapter-IV/subchapter-G/part-488

These deficiencies require particularly detailed, systemic POCs.

Maintaining Evidence of Implementation

CMS and state agencies may request evidence of POC implementation at any time during:

• Revisit surveys

• Federal validation surveys

• Complaint surveys

• Accreditation renewal

• QAPI audits

Documentation requirements fall under 42 CFR §484.110
https://www.ecfr.gov/current/title-42/section-484.110

Agencies should retain POC documentation for several years.

Preventing Future Deficiencies

Long-term strategies include:

• Strengthening internal compliance programs

• Conducting routine internal audits

• Quarterly and annual QAPI evaluations

• Robust Governing Body oversight

• Updating policies annually

• Conducting staff competencies regularly

• Ensuring timely completion of documentation

• Maintaining proactive supervisory visits

A well-implemented compliance program significantly reduces the risk of future citations.

Conclusion

Handling a Plan of Correction after a home health deficiency requires accuracy, timeliness, and a detailed understanding of federal and state regulatory requirements. A well-written POC demonstrates to regulators that your agency can correct issues promptly and maintain ongoing compliance with the Medicare Conditions of Participation and state licensing laws.

If your agency needs assistance writing POCs, preparing for surveys, revising policies, or completing root cause analyses, SummitRidge Consulting provides complete regulatory and operational support for home health agencies nationwide.