On June 16, 2017, CMS issued transmittal S&C: 17-34-ALL. This transmittal set forth changes to the format of Plans of Correction (“POC”) and Allegations of Compliance (“AOC”).

Providers will no longer be required to write their POC/AOC on the right side of the CMS Form 2567 (“2567”). Providers are now allowed to submit the POC/AOC as a separate attachment to the 2567 or continue to write the POC/AOC on the 2567. This change is a departure from past CMS policy that specifically stated that the POC/AOC could not be submitted as a separate document. This change in policy also applies to CLIA laboratories.

The transmittal also reiterated what elements CMS expects for an acceptable POC. These elements are as follows.

  • The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited.
  • The procedure for implementing the acceptable POC for the specific deficiency cited.
  • The monitoring procedure to ensure that the POC is effective and that the specific deficiency cited remains corrected and/or in compliance with regulatory requirements.
  • The title of the person responsible for implementing the acceptable POC.

These elements have been in place for years, but our experience is providers sometimes fail to address each element in a POC. This leads to rejection of the POC by CMS or the State Survey Agency.

Since the 2567 is public information, CMS reiterated the 2567 should not contain Privacy Act or Protected Health Information. Therefore, it is critical that a 2567 redact any resident identifying information.

A link to the transmittal can be found here.