You are not alone. 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 Accreditation Commission for Health Care (ACHC) before a final accreditation status can be determined.

ACHC Hospital Accreditation is a process. After your survey, you will receive a Survey Deficiency Report from your Account Advisor within 10 business days from the last day of your survey. The next step in the survey process requires the hospital to develop Plans of Correction (POCs) for each citation listed in the Survey Deficiency Report; you can access the POCs in Compass. Instructions and examples of completed POCs can be found in the attachments areas of the POC section in Compass to help guide you in developing a thorough plan.

The report will list deficiencies that were identified during the survey and show your organization was not compliant with Centers for Medicare & Medicaid Services (CMS) and ACHC Standards. To address these findings, a POC that details your corrective actions and monitoring activities must be completed in Compass and submitted within 10 calendar days from the date you receive your report.

The ACHC Standards Interpretation Team will work with you to ensure POCs are acceptable and that you are set up for success. Please note that failure to submit an acceptable POC within the required time frame may result in a change of accreditation status to Denial of Accreditation.

POC Requirements

For your POC to be approved, your plan must contain specific information under the following headings:

• Corrective Actions
  • Part A: Actions You Will Take – Your POC should include corrective actions you have implemented, or will implement, to bring the deficiency into compliance. Be very specific. And remember to include the action(s) you took immediately to resolve the deficient finding(s) and a long-term action plan to maintain compliance.
  • Part B: Internal Approval Process – Policy, Process, Actions – This section should detail the chain of events that must occur to obtain approval for each action detailed in Part A.
  • Part C: Education on Compliance and Process – Include plans to educate the appropriate individuals about the corrective actions identified in Part A.

When the corrective actions are identified for Parts A, B, and C, additional information is required as follows:

• • • Title of Responsible Individual: Identify the title of the leader or committee assigned responsibility for ensuring corrective action is completed for each action identified in Part A.
    • Expected Date of Completion (EDOC): All corrective actions must be completed no later than 60 calendar days past the last day of survey.
    • Current Status: Indicate “in process” or “completed.”
  • Part D: Monitoring and Reporting Plan ­– Data to be Collected (Quality Indicators), Monitored, and Reported – This section should detail plans to ensure and sustain compliance with the corrective action(s) identified in Part A.

When the monitoring plan is detailed in Part D, additional information is required as follows:

• • • Title of Responsible Individual: Identify the title of the leader or committee assigned responsibility for ensuring the monitoring and reporting plans are carried out.
    • Start Date/End Date: Indicate the start and end dates of the monitoring period.
    • Frequency: Indicate how often the monitoring and reporting will be conducted.
      
      **IMPORTANT TIPS** When determining your monitoring plan, always include a desired threshold of compliance, along with a committee or senior leader to whom the results will be reported. If these are not defined within your monitoring plan, there is a good chance the plan will be returned to you with a request for revisions.

• • • • Corrective actions related to auditing require a two-step monitoring process:

• • • • • First, include the percentage of the whole to be audited, the frequency of the audit, and the target thresholds. For example, thirty (30) records or 25% of the daily census, whichever is greater, should be monitored on at least a monthly basis until 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.

• • • • Monitoring for corrective actions related to policies should include a policy review to ensure compliance. Monitoring may also focus on a combination of chart audits and policy review.

Deficiency and POC Example

Let’s put this learning into practice in this example:

• Deficiency: Based on medical record review of ten (10) open and closed records of surgical patients, six of ten (6/10) records did not include a completed H&P prior to surgery.
  • Part A: Actions You Will Take
    • Patient charts for remaining surgeries for the day of survey finding and following day were audited to ensure H&Ps were complete.
      • Title of Responsibility: Director of Surgery
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
    • Emergency communication sent to all surgery offices detailing the requirement for H&Ps to be completed prior to patient surgery.
      • Title of Responsibility: Chief Medical Officer
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
    • H&P completion added to Surgical Services daily chart audit form.
      • Title of Responsibility: Director of Surgical Services
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
  • Part B: Internal Approval Process
    
    • Patient medical record audit for surgeries planned 12/10/23 and 12/11/23 and H&P completion added to Surgical Services daily chart audit form.
      • Title of Responsibility: Chief Nursing Officer
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
    • Emergency communication to all surgeons and surgery offices detailing requirement for H&Ps to be completed prior to patients’ surgeries.
      • Title of Responsibility: Chief Medical Officer
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
  • Part C: Education on Compliance and Process
    
    • Real-time education provided to surgical services clinical team regarding H&P requirement prior to surgery.
      • Title of Responsibility: Surgical Services Nurse Educator
      • Expected Date of Completion: 12/10/23
      • Current Status: Completed
    • Education to all Medical Staff regarding H&P requirements.
      • Title of Responsibility: Chief Medical Officer
      • Expected Date of Completion: 1/2/24
      • Current Status: In progress
    • Education to Surgical Services Charge Nurses regarding new daily H&P audit requirement.
      • Title of Responsibility: Director of Surgical Services
      • Expected Date of Completion: 1/2/24
      • Current Status: In progress
  • Part D: Data to be Collected (Quality Indicators), Monitored, and Reported
    
    • Fifty percent (50%) of surgical patient medical records will be audited daily to ensure H&P completion prior to patients’ surgeries. Will audit daily for three (3) consecutive months or beyond until 100% compliance is achieved. After 100% compliance is achieved for three consecutive months, auditing will decrease to 10% of surgery records monthly to sustain compliance.
      • Title of Responsibility: Director of Surgical Services
      • Start Date: 12/12/23
      • End Date: 3/12/24
      • Frequency: Daily
    • H&P audit reports to be reported to Patient Safety and Quality Committee.
      • Title of Responsibility: Director of Surgical Services
      • Start Date: 12/12/23
      • End Date: 3/12/24
      • Frequency: Monthly

What Happens Next?

After you submit your POC to ACHC, an ACHC Standards Interpretation Specialist will review your information and determine if the action steps and the monitoring process(es) 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 are adequate, your POC will be accepted. If it is determined that the action steps or continued monitoring will not resolve the deficient practice(s), an ACHC standards interpretation specialist will contact your organization to request POC revisions.

Once all POCs have been deemed acceptable, your plans will be approved and sent forward for final review and accreditation decision.

Final Status

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

Here to Help

ACHC is more than an accreditor. We are your partners. For more information, or to obtain a copy of the ACHC Acute Care Hospital Accreditation Standards Manual or the ACHC Critical Access Hospital Accreditation Standards Manual, contact your Account Advisor, email [email protected], or call (855) 937-2242.