Achieving Continuous, Substantial Compliance

3006.5 - Achieving Continuous, Substantial Compliance (Rev. 1, 05-21-04) 3006.5A - Introduction (Rev. 1, 05-21-04) In order to safeguard the health, welfare and safety of individuals served within a facility, it is imperative that a facility not only attain substantial compliance in each area of identified deficiency(ies), but that it maintain/remain in continuous compliance. 3006.5B - Duration of a Sanction (Rev. 1, 05-21-04) A sanction is discontinued when the facility’s provider agreement is terminated or when the facility has demonstrated to the satisfaction of the SA that it is in substantial compliance with the Conditions of Participation. 3006.5C - Achieving and Maintaining Substantial Compliance (Rev. 1, 05-21-04) The facilities must establish policies and procedures to remedy deficient practices and to ensure that correction is lasting. Facilities must take the initiative and responsibility for monitoring their own performance continuously to sustain compliance. In order for a PoC to be acceptable, it must include the following elements: 1. Core Elements of PoC: a. How the corrective action will be accomplished for individuals found to have been affected by the deficient practice; b. How the facility will identify other individuals who have the potential to be affected by the same deficient practice, and how the facility will act to protect individuals in similar situations; c. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; d. How the facility will monitor its corrective actions/performance to ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic change to ensure that solutions are permanent; and e. When corrective action must be accomplished.