Understanding Findings & Corrective Action Plans

What happens after the survey is completed and the findings have been written out and posted? What should you do next?

First and foremost, it is essential to review the findings. Don't dismiss them as minor issues or oversights. Next, prioritize the findings and develop a plan for addressing them. Some findings may require immediate attention, while others may be able to wait until a later date. It's important to be realistic about what can be accomplished and when.

Even the best departments sometimes have findings beyond their control. In this instance, it is crucial to understand that the severity of the finding impacts the response. The Joint Commission recently streamlined its response process with their SAFER survey approach. All Requests for Improvement (RFIs) will need a response within 60 days, regardless of severity, but the complexity of the response differs. There are nine categories of severity for the Joint Commission, which combine likelihood to harm (Low, Moderate, and High) with scope (Limited, Pattern, and Widespread).

SAFER Matrix

All RFIs marked as low likelihood to harm and moderate likelihood to harm with limited scope (below the black line, see SAFER matrix ) will require an Evidence of Standards Compliance (ESC) follow-up plan covering the who, what, when, where, & why format.

Any RFIs marked as moderate with a scope larger than limited and all RFIs marked with a high likelihood to harm will require the same follow-up plan with an added sustainability plan that includes leadership involvement and preventative analysis. These RFIs will also be flagged for follow-up by a surveyor on any future surveys and may trigger a resurvey to ensure compliance after the ESC has been submitted.

Other regulatory agencies will have their follow-up requirements that usually involve a written plan of correction with some proof, such as pictures or logs, and they may return to resurvey if deficiencies are severe. Sometimes a resurvey is very focused and only looks at the area identified for correction, but sometimes they are more involved than the initial survey. Because of their nature as a deemed status agency, a "not so good" accreditation survey may also trigger a full survey from CMS to validate the issues identified. That is why it is very important to do everything possible to ensure the initial survey runs as smoothly as possible.

Once a plan is in place, communicate it to your leaders and any other stakeholders who may be affected. Be transparent about the findings and how you will address them. This will help build trust and confidence in your organization. Finally, take steps to prevent future compliance issues. This may involve updating policies and procedures, increasing training for employees, or implementing new systems. The goal is to ensure that your organization is operating in full compliance with regulations while providing high reliable, quality care to your consumers.

Accreditation surveys can be a challenging experience, but it's important to take the findings serious and develop a comprehensive plan for addressing them. By prioritizing the findings, communicating with stakeholders, and taking steps to prevent future compliance issues, you can ensure that your organization is successful and compliant for years to come.

The ONWARD Team is here to support you through the final process of corrective action planning. Contact us today to learn more about our services and how we can help your organization excel onward!