Plan of Correction
A plan of correction (PoC) is the written response a home health agency must submit after a survey identifies deficiencies on the Statement of Deficiencies, Form CMS-2567. It describes how each deficiency will be corrected, how the agency will prevent recurrence, who is responsible, and by what date. The PoC is generally due within 10 calendar days of receiving the 2567, and an accepted PoC is required to stay on track with Medicare participation.
When a plan of correction is required
Any deficiency cited on the CMS-2567, whether standard level or condition level, requires a plan of correction. The requirement applies regardless of who performed the survey: state survey agencies and accrediting organizations both require corrective responses, though accreditors may use their own formats and timelines. The clock is short, generally 10 calendar days from receipt of the 2567, so the response effort should begin at the exit conference, when the agency first hears the findings. For condition-level deficiencies the PoC runs in parallel with an enforcement timeline: compliance must actually be restored, and verified on revisit, before the 90-day termination date, or 23 days under immediate jeopardy.
What a credible plan of correction contains
Surveyors reject vague promises. For each cited deficiency, a credible PoC addresses:
- Correction for the specific patients or situations cited in the finding
- How the agency identified other patients potentially affected by the same practice
- The systemic fix: policy changes, retraining, workflow or staffing changes
- Ongoing monitoring, usually audits folded into the QAPI program, with frequency and thresholds
- The title of the person responsible for implementation and monitoring
- A realistic completion date for each element
The completion dates matter: revisit surveys verify correction as of those dates, and unmet dates convert a paperwork problem into a compliance problem.
Timelines, revisits, and what happens next
After submission, the survey agency reviews the PoC and either accepts it or returns it for revision. Acceptance is not the finish line. For condition-level findings, a revisit survey verifies that corrections are implemented and effective; only then is compliance restored and the termination track closed. For standard-level findings, verification may occur by revisit or by reviewing evidence of correction. If the PoC is rejected, correction dates slip, or a revisit finds the same problems, the agency faces escalating consequences: continuation of the termination timeline, alternative sanctions such as civil money penalties or suspension of payment for new admissions, and heightened scrutiny on future surveys.
Common plan of correction mistakes
The most frequent failure is writing the PoC as a documentation exercise instead of an operations project. Typical mistakes include blaming a single employee rather than fixing the process, promising education as the entire fix with no monitoring behind it, setting completion dates the agency cannot hit, and skipping the look-back for other affected patients. Another is treating the PoC as separate from QAPI: surveyors expect the monitoring plan to live inside the QAPI program with data reviewed by leadership. Finally, agencies sometimes correct the cited chart and not the workflow, which guarantees a repeat citation on the next survey.
Frequently asked questions
How long does an agency have to submit a plan of correction?
Generally 10 calendar days from receipt of the Statement of Deficiencies (CMS-2567). Accrediting organizations set their own submission windows, which are similar. Start drafting at the exit conference rather than waiting for the written 2567 to arrive.
Is submitting a plan of correction an admission that the findings are true?
Submitting a PoC is required to maintain participation, and agencies commonly include a statement that the plan does not constitute an admission of the deficiencies. If the agency disputes findings, it can pursue informal dispute resolution where available, but it must still submit an acceptable PoC on time.
What happens if the plan of correction is not accepted?
The survey agency returns it for revision, and the agency must resubmit quickly because enforcement timelines do not pause. Repeated unacceptable submissions, or a revisit showing the deficiencies persist, can lead to termination proceedings and alternative sanctions such as civil money penalties.