Tennessee Department of Health

1. Tennessee Department of Health Tips for submission of an acceptable AoC/PoC

2. AoC/PoC TIPS AoC/PoC Review • When Immediate Jeopardy is identified, you may submit an Acceptable Allegation of Compliance (AoC) or; • To obtain complete substantial compliance you may submit an Acceptable Plan of Correction (PoC)

3. AoC/PoC TIPS AoC/PoC Review IN CASES OF IMMEDIATE JEOPARDY • Facility may submit an allegation of removal of the IJ (AoC) • CMS & HCF will review the AoC to determine if acceptable • AoC must include: date the IJ was removed and sufficient detail to demonstrate that the IJ has been addressed.

4. AoC/PoC TIPS AoC/PoC Review Sufficient Detail • What corrective action(s) will be accomplished for those residents affected by the Immediate Jeopardy practice. • How you will identify other residents that may have the potential to be affected by this Immediate Jeopardy practice and what corrective actions will you take for those residents.

5. AoC/PoC TIPS AoC/PoC Review Sufficient Detail • What measures will be put into place or what systematic changes you will make to ensure that IJ will not recur. • How the corrective action(s) will be monitored to ensure the IJ will not recur. • What quality assurance program will be put into place including who will monitor and how often.

6. AoC/PoC TIPS • Not a forum for the dispute of deficiencies {use IDR for this process} • Do not use statements with disclaimers such as “this AoC/PoC is inadmissible by any third party in a civil or criminal action” {The AoC/PoC becomes public record as recorded on the CMS 2567}

7. AoC/PoC TIPS • A completion date may not be earlier than the date of the deficient practice or earlier than the exit date of the survey unless the deficient practice was corrected while the survey was in progress.

8. You must place a completion date that you will have a specific deficient practice corrected. This date goes in the right hand column directly across from where you begin the AoC/PoC for each F tag number. Remember if Immediate Jeopardy, your completion date must be within the 23 day date for termination. You must also give at least two days prior to the 23rd day so that a revisit can occur. Should you wait until two days prior to the 23rd day and the revisit finds that your deficiencies are not corrected, then it is to late to resubmit an AoC and your facility will go into termination. It is best to have completion dates as early as possible so that a second revisit can occur if needed

10. AoC/PoC TIPS • If you are addressing a second or third submission of an AoC/PoC make sure you have addressed all the discrepancies found in your previous AoCs/PoCs. • Make sure you edit your AoC/PoC in order not to leave any uncompleted sentences. Also be sure that your PoC can be read and understood by a lay person. • When submitting a corrective action plan for deficiencies cited, you must designate whether the document is an AoC or PoC.

11. With Immediate Jeopardy deficiencies, you must submit a copy of your AoC or PoC to both the Regional Office of Health Care Facilities and to CMS Region IV Office in Atlanta. Address your cover letter with your AoC/PoC to: Faye Vance, Regional Administrator ETRO Debra Verna, Regional Administrator MTRO Shirley Jones, Regional Administrator WTRO Karen Powell, Enforcement Officer, CMS Region IV The addresses will be on your enforcement letters.

12. AoC/PoC TIPS • If you are auditing a process as part of your AoC/PoC explain what tool you will use for this audit and include a copy of the tool with your AoC/PoC . • If you include with your AoC/PoC a table of contents then make sure that all the contents listed are found in the AoC/PoC or it’s attachments. • When conducting in-services for employees you must address how absent and future employees will receive this training.

13. AoC/PoC TIPS • If you make changes or write new policies/procedures please provide copies as an attachment to your AoC/PoC. • If you establish a new training program such as for an Alzheimer’s program then you must submit with the AoC/PoC a copy of the curriculum.

14. AoC/PoC TIPS • If you start a new communication program such as a 24 hour report, walking rounds, stand up reports etc., you must explain how this new report is utilized as well as submit a copy of the policy for the implementation of the report.

15. AoC/PoC TIPS • If in your AoC/PoC you state that an audit is conducted, you must state who conducted the audit (by title), dates of the audit (from-to), findings of the audit, and actions taken as a result of the audit. • All in-services listed in your AoC/PoC must have content described, date conducted, position of person conducting, and disciplines of staff that attended.

16. AoC/PoC TIPS • If your AoC/PoC lists monitoring, then much detail of the monitoring is required, such as who (by title) will monitor, the issues being monitored in detail, the frequency of monitoring as well as the effectiveness found by the monitoring.

17. AoC/PoC TIPS • If your AoC/PoC states that you changed a policy such as a nursing policy on charting frequencies, monitoring of that policy must be done to assure it has been audited for compliance.

18. AoC/PoC TIPS • Do not generalize titles. It is not sufficient to say staff. You must be more specific such as licensed staff, supervisor staff, certified nursing assistants etc. • If you address committees in your AoC/PoC then you should be clear and identify (by title) the members of the committee .

19. AoC/PoC TIPS • Do not use words like non drug intervention, new therapy provider etc. You must explain in detail and be specific such as: group therapy was performed by a Licensed Clinical Psychologist, Medical Director, Director of Nurses etc. • You must address each resident identified in each deficiency.

20. AoC/PoC TIPS • You may not cross reference in your AoC/PoC. You may find that some of the deficiencies have the same findings and you may find that the citations may have cross references. The cross referencing in citing deficiencies is legally allowed when specific violations affect more than one citation. The AoC/PoC has different requirements in that the corrections must be detailed and specific to each deficiency cited. If you cross reference in your AoC/PoC it will result in an unacceptable AoC/PoC.

21. IJ Deficiencies January –April 2008 Tags # of Times Cited F-490 Administration 7 F-281 Service of Prof. Stds 5 F-520 QA 5 F-319 Mental & Psychological function 3 F-157 Notification of Changes, 3 F-250 Social Services 3 F-F-327 Hydration 3

22. IJ Deficiencies January –April 2008 Tags # of Times Cited F-223 Abuse, 2 F-225 Report and Investigate incidents 2 F-226 Screen Emp. For Abuse, Neg. Missap. 2 F-279 Dev., review, revise care plans 2 F-280 Dev. Care plan after 7 days of Assess. 2 F-333 Significant Medication Errors 2 F-353 Sufficient Staff 2 F-501 Medical Dir. 2 F-502 Lab. Services 2

23. IJ Deficiencies January –April 2008 Tags # of Times Cited F-224 Dev. & follow Abuse Policies 1 F-287 MDS Transmission 1 F-314 Pressure Sores 1 F-323 Accidents 1 F-325 Nutrition 1 F-332 Med. Errors >5% 1 F-428 Drug Reviews 1 F-441 Infection Control 1 F-495 CNA working over 4 Mo. Not Cert. 1 F-505 Laboratory Service 1