CHAP Provider Education and Training - Plan of Correction
Description: CHAP, the Community Health Accreditation Program, has implemented a new policy requiring all organizations to submit a Plan of Correction (POC) for any CHAP standards deficiencies noted during a site visit. Intended to guide and support CHAP accredited organizations in the performance improvement process, CHAP’s web based POC toolset is easy to use, and structured to assist organizations in carrying out correction and monitoring actions to bring their organizations back into compliance with CHAP Standards of Excellence. This same POC Toolset is used for home health and hospice deemed organizations, who also respond to CMS deficiencies. This presentation introduces CHAP’s new policy and procedure, the POC toolset and all of the steps required to develop an effective and acceptable Plan of Correction.
Click here to watch the presentation!CHAP Webinar Series: CHAP Plan of Correction Overview
TO: All Agencies
FROM: Terry A. Duncombe, President & CEO
DATE: August 4, 2009
RE: Plans of Correction
Thank you for your ongoing work to improve quality in community based care! CHAP, too, is always examining our Standards of Excellence and our operations and processes for ways we can improve establishment of a foundation for quality as well as supporting you in your pursuit of excellence. We are implementing a change in processes that we believe will further our foundation and guidance to you in improving quality.
Effective for home health and hospice site visits ending on or after September 1, 2009, CHAP will request organizations provide a written response to all citations found during the site visit. CHAP will issue a written report of all CHAP required actions. For those organizations seeking Medicare deemed status, all CMS deficiencies will also be included. Along with these findings, organizations will receive instructions on the development of a Plan of Correction. The organization then must develop and document a Plan of Correction and submit it to CHAP for review. Final acceptance of the Plan of Correction will be required in order for the Board of Review to finalize the accreditation determination. Plan of Corrections procedures will be required for all other organizations by the end of 2009.
CHAP has long used the term Required Action, and has expected organizations to correct any deficiencies as described in the Required Action(s). Now, CHAP will require that a written Plan of Correction be developed immediately after the Site Visit and address any deficient practices. We believe this process change will give stronger guidance and incentive to rapid correction of deficient practices and support accredited organizations in the discipline of continuous quality improvement.
The Plan of Correction will replace the Progress Report, which many organizations are accustomed to developing and providing at some time during the accreditation cycle. Also, follow-up on implementation and effectiveness of the Plan of Correction will occur during a Focus Visit at some point in the 3 year Accreditation Cycle, if required by the Board of Review. If not, follow-up on the effectiveness of the implementation will be assessed during the renewal of accreditation site visit, which will occur within 36 months, at the latest.
It is CHAP’s intention to create and use complete electronic documents for this process. The CARES Client Portal will ultimately be the vehicle to facilitate communication of citations and Plans of Correction, but until that complete functionality is available, we plan to function via email.
As we considered these improvements to our accreditation procedures, the input you have provided us in phone calls, letters, meetings and trade shows was very important. Many of you have asked why we did not have a Plan of Correction process, and most of you have strongly supported electronic documentation and communication initiatives, such as our web based CARES submitted self studies. All of you have demonstrated commitment to quality in seeking to meet CHAP’s Standards of Excellence and we look forward to continuing to serve you in your mission of excellence in community based care.
Please continue to watch this website for more communication and information on the upcoming changes. We will be holding several webinars to clarify our expectations regarding Plans of Correction, and answer your questions. Please check this web site for details about schedules and registration.
Frequently Asked Questions:
Below, please find a FAQ regaining the Plan of Correction policy and webinars. Information is updated regularly so check back often. For questions not addressed in this FAQ, please email pocquestions@chapinc.org for assistance.
--
Q: Do I have to attend all four (4) webinar sessions?
A: No, all 4 sessions are the same training about our new POC procedures.
--
Q: If I cannot attend a scheduled session, how do I learn more?
A: We plan to post recordings of our webinar sessions, and will offer more in the future. To download a copy of a recording, please check back on this page for more information. Also, when you have a site visit and a need for a POC, CHAP will provide guidance and tools at that time.
--
Q: Do I have to prepare a plan of correction today?
A: Plans of Correction are being done by certain CHAP accredited organizations today. If you have one due, you will have received communication from CHAP individually. ALL home health and hospice organizations will being preparing Plans of Correction for site visits ending September 1 or later, with all accredited organizations beginning to prepare Plans of Correction by the end of 2009. CHAP will make it clear if you have a plan of correction due.
--
Q: What if I cannot get my POC done on time?
A: You need to speak with a Director of Professional Services. In very special circumstances, an extension may be granted. Each organization will have about a month to prepare a POC. Organizations should start with the verbal findings discussed at the exit conference and then be prepared to document their plans once the report is received from CHAP 10 business days later. The organization will have 10 calendar days after that to document and submit their plan of correction.
--
Q: What if I disagree with a finding?
A: This needs to be discussed with your site visitor during the course of the survey. All findings that are cited on the Plan of Correction must be addresses. CHAP does have reconsideration and appeals procedures for accreditation decisions that are disputed.
--
Q: I have not received my report yet. How do I complete a POC?
A: Attend one of CHAP's webinars over the next few weeks. After a site visit, CHAP will provide specific directions.
--
Q: How do I know if a POC is required?
A: Your site visitor will tell you if you will have a plan of correction, and CHAP will send you the deficiencies along with instructions, 10 business days after the end of your site visit.
--
Q: How does the POC affect competitive bidding?
A: The only impact might be if an organization failed to submit an acceptable POC. That would keep the organization from becoming accredited, and a non-accredited organization may not participate in competitive bidding.
--
Your Customer Relations Representative will, as always, be your first contact about any CHAP issues, and will be working to assist you through this transition. Please send any general questions or concerns to POCquestions@chapinc.org. We will respond on the web site to global issues and try to address individual concerns.
