Follow-Up on PoCS

2732 - Follow-Up on PoCS (Rev. 1, 05-21-04) 2732A - Post-Survey Revisit (Rev. 1, 05-21-04) The SA follows up on all deficiencies cited in PoCs. In some cases, the cited deficiencies may be of a nature that a mail or telephone contact will suffice in lieu of an onsite visit (e.g., the facility agreed to amend its bylaws or written policies). A mail or telephone contact is acceptable as long as the SA has no reason to question the validity of the reported corrections. However, an onsite visit is generally required for deficiencies concerning quality of care. Because the LTC survey process focuses on the care of the resident, revisits are almost always necessary to ascertain whether the deficiencies have indeed been corrected. (See Appendix P for further instructions about follow-up surveys in SNFs and NFs.) If documentation or onsite verification is warranted, the SA obtains appropriate verification before reporting a deficiency as corrected. The revisit (or the mail or telephone contact) requires that the SA complete a Post-Certification Revisit Report (Form CMS-2567B). 2732B - Form CMS-2567B (See Exhibit 8) (Rev. 1, 05-21-04) At the time of the follow-up visit to verify corrections of deficiencies previously cited on Form CMS-2567 and/or when corrections are verifiable by telephone contact or mail, the SA completes Form CMS-2567B for the corrections that have been completed. The SA enters: 1. Provider or supplier identification information; 2. Date of the revisit or date of verification; 3. Prefix tag; 4. Corresponding regulatory reference cited on the original Form CMS-2567; and 5. Date the correction was accomplished. If possible, the revisit is to be conducted by a member(s) of the survey team who cited the original findings. The SA has the completed form initialed by the reviewing official and signed by the surveyor and retains the fourth copy for its provider file, mails a copy to the provider or supplier, and forwards a copy to the RO or SMA, as appropriate. If, at the time of the revisit, some deficiencies have not been corrected, the SA completes another Form CMS-2567 summarizing the deficiencies not corrected by data prefix tag number. The SA asks the provider or supplier to provide a revised PoC with new completion dates. The SA annotate under the heading “Statement of Deficiencies and Plan of Correction,” “Summary of Deficiencies Not Corrected on a Follow-Up Visit,” and enters the date of the revisit beneath the date of the survey. The SA associates the fourth copy of the revised Form CMS-2567 with Form CMS- 2567B, retains a copy for its provider file, sends a copy to the provider or supplier, and forwards the remaining copies to the RO or SMA, as appropriate. The SA considers whether the uncorrected deficiencies affect the ability of the provider or supplier to meet the CoPs or Requirements. If they do, the SA documents noncompliance and initiates a termination action. 2732C - Notifying Governing Bodies of Continuing Deficiencies (Rev. 1, 05-21-04) Generally, the SA deals directly with the administrator or director on a routine basis. However, the SA may notify the governing body if an administrator or director has been ineffective in correcting deficiencies. If the SA does so, it advises the administrator or director.