Corrective Action Notice Form

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Corrective Action Notice Form Powered By Docstoc
					Corrective Action Plans
A Guide To Completion and Progress
         Reporting to DMA
An illustration…

• The following slide is an illustration of what
  the new form looks like.
Notice the new layout
of the form with more
room for your data to
 be entered. This can
        be used
  electronically and
  printed or you may
 print and handwrite
      on the form,
whichever you prefer.
Basic Process:
• A – This number and description comes off your QA form and/or
  your post review letter. It identifies the deficiency/key aspect
  description. List both the number and the description in this
• B – What are you going to do about it specific to this patient(s) or
  event(s)? There will be more than 1 step/task documented here.
• C – What is your agency going to do to prevent it from happening
  with the rest of your caseload? List multiple specific tasks to be
  done in this column specific to other charts or events not yet
  found or reviewed to ensure that the problem isn’t larger than
  originally discovered.
• D – Identify the person in charge fixing the specific things
  identified in column C and D. List the date that each action will be
  completed by the person you identified in column E.
• E – How do you know it’s getting done? What system of
  monitoring did your agency put into place to ensure that the plan
  gets completed in its entirety and how will you monitor on an
  ongoing basis to ensure that the problem no longer exists or
  doesn’t come back.
Progress report

• The next slide illustrates the progress
• This report is the form that is completed
  AFTER the initial corrective action plan
  has been formulated.
• It recaps the deficiencies and what your
  agency did to correct the problem, then
  lists progress made toward the completion
  of the initial plan.
                        Once again,
• Click to add text     you may use
                       the electronic
                      version or you
                         may make
                         copies and
                      information on
                          this form.
  Most important questions to ask:

• Does it make sense?
• Is my plan to solve the problem really
  going to solve it?
• Is it reasonable?
• Is it achievable?
• How does it apply to
  the rest of my case load?
Things to include:
• Identify what happened
• Identify why it happened. Ask yourself why.
  When you can quit asking “why”, you have
  reached the root of the problem and then begin
  getting it fixed.
• How are you going to fix it?
• Who’s going to fix it? (It’s not a 1-person show)
• When are they going to be done fixing it?
  (tomorrow, next week, by the end of the quarter,
  etc. – not next year)
• How are you going to keep it fixed and keep it
  from coming back again?
 More things to include:
• Policy & procedure changes that affect how your agency
  performs day to day activities
• Targeted audits or more frequent self-reviews to ensure
  that you got it licked
• Communication – memos, newsletters, letters to your
  clients, etc (just make sure you keep copies of all
• If you need to pay back money, get it done. This looks
  REALLY good on your agency in the eyes of Program
• Training, training, training! (From the ground up – your
  aide to your administrator; make it a requirement in
  orientation and make it happen more than once during
  employment with your agency)
Things to avoid:
• Restating the obvious; restating that the nurse
  will do visits on time is not appropriate. You
  need to state how this will take place.
• Piling it on one person; (share the load please)
• Unreasonable timelines (May 2012 is an
  unreasonable timeline)
• Poor follow through – if you write it down, make
  it happen.
• If it doesn’t work, try something else – remember
  the Corrective Action Plan is just a “plan” and it
  can change as your agency’s needs change.
  Just remember to update your plan so you have
  documentation to prove what you did.
  What constitutes a payback?
• RN is not certified – any services provided to
  clients that this nurse assessed or supervised
  prior to the date she completed training and
  became certified is not billable to Medicaid.
• Supervision visits are late – anything beyond the
  90th day if service has been provided is not
  billable until supervision is completed.
• PACT form does not show at least 2 deficits in
  ADL’s – payback from date of assessment that
  did not document the qualifying ADL’s.
  What constitutes a payback?
• MD signature is outside of 60 day timeline - if he
  has not signed his verbal order within 60 days,
  payback every day from day 60 until the day the
  PACT is signed.
• MD order for continued service {reassessment}
  (verbal or written) is older than 365 days.
  Payback every day from day 365 until you obtain
  an order for service (either verbal or written).
• Services billed do not reconcile with what was
  authorized and/or provided. If you billed
  something outside of what the MD signed for or
  outside of what the aide did, it’s a payback.
 This information is first.
 List your provider name
    and your provider
   address. This should
  correspond to the site
  that was reviewed and
    should match the
information on the home
    care license of the
   Your Medicaid
  provider number
goes here. It is the
  number found at
   the top of your
 remittance advice
from Medicaid and
   this number is
  usually a 7-digit
number beginning
       with 66.
 Note the multiple page
numbers. For example, if
you have 4 deficiencies,
 you will need to use 4
   different pages to
address each deficiency;
 therefore, this section
 will say “page 1 of 4”.
       The person
   responsible for the
implementation of this
 plan should sign and
 date on this line. This
  person has ultimate
  responsibility to see
 that the entire plan is
   carried out and the
   problems identified
    therein have been
resolved according to
      clinical policy.
 If your agency has
  been reviewed or
surveyed by anyone
 such as CCME, list
   the date that the
     survey was
 conducted on this
   Row A should contain the
number and the description of
 the deficiency found in your
 agency. This information will
be on your letter from DMA. If
   you have more than one
  deficiency, list only the first
one here. Use a separate page
    to list any subsequent
 deficiencies. For example, if
 your agency was deficient in
  4A and 5D, 4A would go on
this page and 5D would go on
        a separate page.
 Row B lists what you plan to
  do to correct the deficiency
specific to the event or patient
 reviewed. You will have more
than one item here because it
will take more than one single
    step to correct most any
problem. When you list them,
you should label them B1, B2,
   B3, etc. This will make for
quick reference later on in the
plan and also on any progress
  reports that you will have to
          submit later.
   Row C will contain any actions
  that you will take that will affect
    your agency as a whole. For
     example, if you are going to
provide an inservice to your nurse
      that caused you to have a
      deficiency of late/untimely
  supervision, you would list that
 particular nurse in row B; in row
    C, you would list your entire
   nursing staff (all your RN’s) to
 ensure that they too are aware of
     the policy and are providing
 timely supervision to your entire
    client census. Again, you will
have more than one step here and
they should be labeled C1, C2, C3,
       etc. for future reference.
Row D lists who is responsible
 for each action. For example,
      B1 might be the RN’s
responsibility. B2 might be the
billing person’s responsibility,
 while B3 and C1 might be the
   role of your administrator.
  Make this a team effort and
include multiple individuals to
be responsible for the various
steps that it will take to correct
           the problem.
  Row E is where you identify
 how you intend to continually
monitor the situation and track
the possibility for or any actual
 recurrence of the deficiency.
 Again, multiple things will go
 here such as implementation
of a tracking system as E1 and
 more frequent internal record
   reviews as E2, and so on.
   Now that you have finished the
            initial plan…
• Submit to DMA per their given timeline in your
• If your plan is accepted, you will be notified by
• You will at some point in time need to complete
  a progress report to them to show what kind of
  progress you are making toward the goals you
  set out in your initial plan of correction.
• DMA will notify you when your first progress
  report is due to them.
• The form to use looks like this…
This is the first page of your
progress report. This report is
completed after your initial
corrective action plan has been
completed and this form tells
how your agency is making
progress toward achieving all of
the things you identified in rows
B and C on your initial corrective
action plan. You may have more
than one progress report so you
will label this form according to
the number of progress reports
you have completed. If this is the
first one, “1” will go here.
If you have multiple deficiencies that you
have to report progress on, you will have
multiple pages here just like you did with
the initial corrective action plan form. For
example, if this is the second of 4 pages,
    you will list “page 2 of 4” at the top.
   Once again, you will list
  your agency’s name and
  your agency’s address in
 these blocks. They should
 correspond with the same
information that you put in
these blocks on your initial
   corrective action plan.
Medicaid provider number is a
7-digit number that begins with
        66. (Ex: 6600999)
The top arrow indicates the date and
   signature of the person who is
   ultimately responsible for this
 progress report and the corrective
actions as a whole. The lower arrow
indicates the date your agency was
 surveyed, such as the date of your
           CCME review.
Row A should be a duplication of row
 A on your initial corrective action
 Row B will list each item (B1, B2, C1,
    C2, etc.) from your initial plan of
   correction and what progress you
 have made toward completing those
items. For example, if B3 was that the
  RN would complete PCS training by
1-4-08 and she completed it on 1-2-08,
 you would list that here as “B3 – RN
     will complete PCS certification
training by 1-4-08. Training completed
 on 1-2-08 and certificate is present in
 RN’s personnel file.” You would also
attach a copy of that certificate to this
 progress report when you send it to
  DMA as proof it actually happened.
 There will be more than one line item
  here so elaborate on EVERYTHING
                 you did.
     Row C is the place to list your agency’s
 monitoring tools such as tracking systems you
 put in place to make sure nursing supervision
 was done timely, etc. You will also write a short
 narrative of the policy and procedure changes
   you made as a result of the entire planning
 process to ensure that your agency increases
  their awareness of issues and plans ahead to
address things that come up in the future. Show
 what lessons you learned from the experience
as a whole and how the things you are doing are
        improving your agency. Submit any
documentation that backs up these statements.
More things to consider…

• DMA may ask you to submit your internal QA
  and the PACT forms along with the last month of
  service notes to prove that you are making a
  valid effort to achieve compliance.
• Cycles of supervision notes and service
  deviations may also be requested so that DMA
  can perform a “desk audit” of what you are doing
  and achieving with this plan and progress report.
More things to consider…

• If your actions are not fixing your
  problems, dig deeper to find out what else
  you can do.
• Revise your plan to include new or
  additional strategies to actually correct the
  problem and prevent its recurrence.
Now submit!

• This completes your corrective action plan
  and/or your progress reporting.
• Follow the instructions on the letter from
  DMA as to submission deadlines and
  return addresses.
• Congratulations! You and your agency are
  on the road to success by improving the
  quality of the care you provide!

Description: Corrective Action Notice Form document sample