5 Steps to Writing ASC Plan of Corrections

Un-announced inspections can be stressful if you are not prepared.  If deficiencies are identified during your inspection you will need to work on getting your ASC in full compliance immediately.  It is required that you submit a complete Plan of Corrections within 10 calendar days of the date of your deficiency letter.  The letter (describes the required components that must be addressed for each deficiency) and accompanying CMS Form 2567 which list the deficiency cited. You must provide each corrective action & cross-reference it to the appropriate deficiency noted on the CMS Form 2567.

The following is a breakdown of the required components you need to address for each deficiency listed in red on the CMS Form 2567.  Underneath the component listed in blue will be an explanation to help simplify the process for you (this is how I respond when I prepare POC for clients).

What corrective action (s) will be accomplished for the patient (s) identified to have been affected by the deficient practice?

Make sure you describe the action that will be taken to correct each deficiency.

How other patients having the potential to be affected by the same deficient practice be identified and what corrective action will be taken?

You want to make sure you provide a description of how the action will improve the process that led to the deficiency.

What immediate measures and systematic changes will be put into place to ensure that the deficient practice does not recur?

Describe the procedure for implementing the plan of correction.

A description of the monitoring process and positions of persons responsible for monitoring.  How the facility plans to monitor its performance to ensure corrections are achieved and sustained.  The plan of correction must be implemented, corrective action evaluated for its effectiveness and it must be integrated into the quality assurance system.

You want to identify the individual responsible by their job description i.e. Nurse Manager, monitoring activities that will be conducted including time frames and how your center will sustain compliance.

Dates when corrective action will be completed.  The corrective action completion date must be acceptable to the department.  The deficient practice should be corrected immediately.  This date shall be no more than 30 calendar days from the date the facility was notified of the non compliance.

Provide a completion date of the deficient practice.

Below is a summary statement of a deficiency from an inspection(per CMS interpretive guidelines):


(1) The ASC must maintain a written disaster preparedness plan that provides for the emergency care of patients, staff and others in the facility in the event of fire, natural disaster, functional failure of equipment, or other unexpected events or circumstances that are likely to threaten the health and safety of those in the ASC.

(2) The ASC coordinates the plan with State and local authorities, as appropriate.

(3) The ASC conducts drills, at least annually, to test the plan’s effectiveness. The ASC must complete a written evaluation of each drill and promptly implement any corrections to the plan.

This STANDARD  is not met as evidenced by: Based on document review and interview, the facility failed to plan for the emergency care of patients, staff and others in the event of natural disaster, functional failure of equipment or other unexpected events or circumstances that are likely to threaten the health and safety of those in the ASC.


On September 3, 2013 at 3:30 p.m., the facility’s policies, procedures and records of the facility’s documents were reviewed.  This was accompanied by an interview of Employee 1.  A generic disaster plans was provided along with those covering the occurrence of fire.  No mock drills had been conducted annually to test their plans for their effectiveness and to provide a written evaluation of the exercise of existing plans.  In the absence of drills there was no evidence of coordination of disaster preparedness activities with local or State agencies.

The following is the Plan of Correction addressing the deficiency:

Specific action taken for the patient affected by the deficient practice will be to create a disaster preparedness plan, coordinate the center’s plan with local authorities and to conduct a drill to test the plan for its effectiveness.

The corrective action will be met by contacting LA county emergency preparedness & response program to notify them that we have a Medicare certified surgery center & want to participate in the community.  A plan will be created specific to the center to address emergencies, evacuation, defend in place, evacuation of special needs patients, fire prevention and frequency of drills.

The safety officer will be responsible for the development of the plan, scheduling & overseeing drills, critiques of drills, coordinating the plan with local authorities, reporting & communication of these activities to QAPI.

Immediate measures & systematic changes that will occur to ensure that the deficient practice do not recur will be met by conducting a drill to test the components of the plan, have the Governing Body approve the plan, &  before drill is conducted have staff in-serviced on the plan & provide documentation.

This will be completed by 10/03/13

Monitoring will be conducted on a quarterly basis by the safety officer.  Although the annual disaster drill is to be held separately from the quarterly announced/unannounced fire drills, the safety officer will use the data to support the overall effectiveness of the plan which is reported to the QAPI.

In Conclusion:

Refer to CMS interpretive guidelines and/or your accrediting organization standards manual when preparing your Plan of Corrections.

You should be correcting the problem and writing the Plan of Correction simultaneously.  If you have documentation to support that you have corrected the deficiency submit it with your Plan of Correction.

Here’s to your success,


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