Nearly all organizations surveyed for accreditation are cited for deficiencies. To address deficiencies, an organization must develop an effective Plan of Correction (POC) and submit it to ACHC before a final accreditation status is determined. This is the final step in the accreditation survey process.

After your survey, you will receive an accreditation decision letter, survey Summary of Findings (SOF), and POC form from your Account Advisor within 10 business days from the last day of your survey for ACHC Hospice Accreditation.

The SOF will list deficiencies identified during the survey and identify requirements for compliance with ACHC Standards. To address these findings, a POC form must be completed that details your corrective steps and monitoring activities. Approval of your POC must be received from ACHC.

The completed POC form must be submitted to ACHC within 10 calendar days from the date of the Summary of Findings.

POC Requirements
For your POC to be approved, your form must contain specific information under the following headers:

• Plan of Correction. In this column, provide details of the specific action steps your organization has taken or will take to address the identified survey deficiencies.
• Typically, the POC includes corrective actions you have implemented or will implement, such as re-educating your staff and/or revising a policy and procedure. You must describe the specific actions taken or will be taken to ensure deficient practices are resolved.
  • For example, if a deficiency was due to staff failing to follow organizational policy or the patient’s plan of care, the action step required for compliance would be to re-educate staff.
  • If the deficiency was a result of an insufficient policy, the action step required for compliance would be to revise the policy and educate staff on the revised policy.
• Date of Compliance. This column notes the date the corrective action steps occurred or will occur.
  • For deficiencies cited at the standard level, action steps must be implemented within 30 calendar days from the day the organization receives the accreditation decision letter, SOF, and POC form.
  • For deficiencies cited at the condition level, action steps must be implemented within 10 calendar days from the day the organization receives its decision letter, SOF, and POC form.
• Title. In this column, provide the title, not the name, of the individual responsible for ensuring corrective actions have been or will be implemented.
• Process to Prevent Recurrence. In this column, provide details on the ongoing monitoring process to ensure that actions taken or will be taken are effective at correcting deficiencies.
  • There is a two-step monitoring process for deficiencies related to medical record reviews and personnel files. For corrective actions that require chart audits:
    • First, include the percentage of charts to be audited, the frequency of the audits, and the target thresholds. Ten records or 10% of the daily census, whichever is greater, must be monitored on at least a monthly basis until the thresholds are met.
    • Second, the monitoring step must include actions for continued compliance once target thresholds are met. This usually involves reducing the percentage of charts to be audited and/or reducing the frequency of audits.
      • For example, the continued monitoring step could be to audit 10% of active charts on a quarterly basis to ensure the desired threshold is maintained.
  • For an insufficient policy, monitoring should include an annual policy review to ensure compliance. Monitoring may also focus on a combination of chart audits and policy review.
    • For example, if the deficiencies were related to the patient rights and responsibilities statement and applicable policy, the corrective actions would be to revise the policy and patient rights and responsibilities statement, and then conduct chart audits.
    • Initial chart audits should be conducted on 10 records or 10% of the daily census, whichever is greater, on at least a monthly basis until the target threshold is met. For continued monitoring, audit 10% of active charts on a quarterly basis to ensure the desired threshold is maintained and review policies annually.

Next Steps
After you submit your POC to ACHC, an ACHC clinical specialist will review your information and determine if the action steps and the monitoring process to prevent recurrence will resolve the deficient practice(s) and ensure ongoing compliance.

If it is determined that the action steps and/or the continued monitoring will resolve the deficient practice(s), a “Yes” will be documented in the POC Compliant column on your POC form. If it is determined that the action steps or continued monitoring will not resolve the deficient practice(s), a “No” will be entered on the form. The ACHC clinical specialist will provide an explanation of “No” decisions in the Comments section of the form.

You will be notified about the approval status of your POC. If your POC is not approved, you will be asked to revise your POC.

Failure to submit an acceptable POC within the required time frame may result in a change of accreditation status to Denial of Accreditation.

Evidence
If evidence is required to support your POC, a “Yes” will be noted in the Evidence Required column of the form. All evidence must be submitted to ACHC within 60 days of the receipt of your Summary of Findings. If evidence is requested and not submitted within the required time frame, accreditation can be terminated.

Evidence will be reviewed and, if approved, a “Yes” will be documented in the Evidence Approved column on the POC form. If evidence submitted is not approved, a “No” will be documented in the column. The clinical specialist will provide an explanation of the “No” decision, and further supporting evidence will be required to be submitted.

Final Status
Your final accreditation status will be determined upon review of your submitted POC and supporting documentation. All fees must be current before ACHC sends you final notification of your accreditation status.

Here to Help
ACHC is your partner in accreditation. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.