***Always use the term "alleged" when answering deficiencies on a 2567!!!***

Disclaimer Statement put at the top of 1st page of 2567

This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of
Correction is not an admission that a deficiency exists or that one was
cited
correctly. This Plan of correction is submitted to meet requirements
established by state and federal law.

Disclaimers remind readers that there are two sides to every story. Then consider a POC addressing, let’s say, an obstructed feeding
tube--in this way:

Tag 3221 It is the policy of (facility name) to provide residents with appropriate treatment and services to prevent aspiration
pneumonia, diarrhea, vomiting, dehydration,
metabolic abnormalities and nasopharyngeal ulcers, and to restore, if
possible,
normal eating skills.

Please note that it is common for the flow of a feeding tube to become temporarily obstructed for several reasons: a
resident's handling of the tube; a manufacturing
imperfection revealed after use; drug-nutrient interaction causing
formation of
slow-dissolving compounds in tube lumen; or incompletely dissolved
formula
secondary to mixing technique of manufacturer. In this case, resident
number
five's gastrostomy tubing was immediately replaced on (date) after
surveyor
reported to nurse. The director of nurses visually inspected the new
tubing to
ensure the absence of defects. The replaced tubing worked properly.

To enhance currently compliant operations and under the direction of the director of nurses, on (date) all nursing staff will receive
in-service training regarding state and federal requirements for feeding
tube
appropriateness and the facility's feeding tube use policy and
procedure. The
training will emphasize the importance of inspecting tubing and
maintaining
open passage, as well as reporting defects to a licensed nurse or
supervisor
immediately.

Because all residents receiving tube feedings are potentially affected by the cited deficiency, on (date), the director of nurses compiled a
list of all residents receiving tube feedings. The director of nurses
then
checked all residents with feeding tubes to ensure proper working order
of all
equipment. The director of nurses then checked feeding tube supplies.
The
director of nurses observed that all resident feeding tubes were working
properly and all feeding tube supplies appeared in good condition. No
other
residents were affected.

Effective (date), a quality-assurance program was implemented under the supervision of the director of nurses to monitor feeding tubes to
ensure proper operation. The director of nurses or designated quality assurance representative will perform
the
following systemic changes: randomly checking, weekly, three residents
who are
receiving tube feeding to ensure that the feedings and equipment are
working
properly. Any deficiencies will be corrected on the spot, and the
findings of
the quality-assurance checks will be documented and submitted at the
monthly
quality-assurance committee meeting for further review or corrective
action.

This sample POC format can be used to respond to any deficiency, even Life safety Code Deficiencies. Make sure to
include the facility policy statement in reference to the cited
deficiency, and
use language that supports and defends the facility actions and
reactions.
Thoroughly outline any corrective action: how other residents
potentially
affected were identified, systemic changes and quality assurance
monitoring
plans.

The recommended frequency of quality-assurance monitoring--whether it's daily, weekly, bimonthly, or monthly--would depend
upon the severity of the cited deficiency. The quality-assurance
committee has
the authority to discontinue quality-assurance monitors once they are
confident
that the deficiency is resolved. Remember, though, that in any case, it
is
simply smart protocol to do follow-up monitoring both three months and
six
months after discontinuing the original monitor.

Another tip: When writing the POC, avoid using industry abbreviations such as DON, DSD, DSS, AD, etc., because a Program Manager for
DADS might reject the POC and require that it be rewritten with
unabbreviated
titles.