Posted in: Triangle Times Today
Volume 3 | Issue 10 | October 2024
Find and Complete the Plan of Correction in 1095 Engage
The bedrock of AAAHC Accreditation lies in the 1095 Strong, quality every day philosophy which promotes ongoing improvement within the operations and business sides of a health care center.
Following a survey, AAAHC requires each organization to correct all cited deficiencies. In some cases, organizations may be required to electronically submit a Plan of Correction (POC) to AAAHC through 1095 Engage. This requirement applies to all AAAHC Accreditation and Certification programs, though the requirements for POC submission vary by program. If an organization is required to submit a POC, AAAHC will email the Primary Contact and assign them a task in 1095 Engage.
Where to go to complete the POC
The 1095 Engage POC tab provides a one-stop-shop for all things POC. The POC Overview Card contains the POC due date, along with a link to the POC Letter. For Medicare Deemed Status ASCs, page two of this letter indicates whether any CMS Conditions for Coverage (CfCs) were cited at the condition level.
How to complete the POC in 1095 Engage
The left-hand side lists all of the Standards requiring submission of a POC. Click into each Standard identifier to complete the POC components on the right-hand side. An acceptable POC must include the following six components for each deficiency:
- Plan of Correction Details — Brief description of the actions to be taken to correct the deficiency and achieve compliance
- Plan of Correction Documentation — Evidence of corrections to be implemented, e.g., work orders, service contracts, draft policies
- Correction Effective Date — Date that the corrective actions will be completed. Corrections must be completed within 30 days of the POC request
- Evidence of Compliance — Evidence of how the correction was made, e.g., approved policies, audit templates, in-service records, training or audit schedules, photographs, paid invoices
- Responsible Party — Title of specific person, committee, or party responsible for ensuring the POC is effective. Do not use individuals’ names
- Monitoring Activities — Ongoing, specific actions to be performed to ensure the corrections are effective
When all components of all POCs are complete, click the teal submit button at the top of page to send the POC to AAAHC for review.
Revisions may be required
In some cases, AAAHC will return the POC for additional information. If this happens, AAAHC will email the Primary Contact and assign them a task in the system. The left-hand side card with the Standards has a column titled Status Indicator which will identify if the POC is accepted or not accepted. The status is also viewable in each Standard.
What to do to contest findings
To disagree with any of the deficiencies in the POC, check the “Object to Compliance Rating” box, complete the required fields, and upload evidence documenting the organization’s compliance at the time of the survey. Finally, the POC is an organization’s only opportunity to contest findings. Additional objections will not be considered after the POC is accepted.
Next steps
When AAAHC accepts the POC, the POC complete date populates in the system. Download a copy of the final document for the organization’s records. The Accreditation Committee reviews the POC and Survey Report and renders an accreditation/certification decision.
If an organization fails to submit an acceptable POC within the required timeframe, accreditation/certification may be denied or revoked and, if in the Medicare Deemed Status Program, recommendation for Medicare certification or participation in Medicare Deemed Status may be denied.
The 1095 Engage Help Curtain contains additional instructions and guidance on the POC submission process.
Frequently Asked Questions: Submitting a POC in 1095 Engage
How many days do I have to complete my POC?What if my POC is not submitted by the identified due date?
If you believe your organization will be delayed in submitting its POC within the required timeframe, accreditation/certification may be denied or revoked and recommendation for participation in Medicare Deemed Status may be denied, if in the Medicare Deemed Status Program. Therefore, contact AAAHC at ASOperations@aaahc.org as soon as possible.
My POC due date falls on a weekend or holiday. Can I get an extension?
As AAAHC requires POC submission within a specified number of calendar days (varies by program), sometimes these dates will fall on weekends and holidays. Unfortunately, extensions cannot be honored. Please contact AAAHC at ASOperations@aaahc.org as soon as possible if you believe your organization will be delayed, and submit your POC as soon as possible.
How many days do I have to implement corrections?
AAAHC requires corrections to be implemented in the facility within 30 calendar days from receiving the plan of correction request.
What if I cannot make all corrections in the 30-day timeframe?
All corrections must be implemented within 30 calendar days.
Medicare Deemed Status Program Only: Some Life Safety Code® and Health Care Facilities Code deficiencies may not be feasible to correct in 30 calendar days. If corrections are anticipated to take longer than 60 days, the ASC can request a time-limited waiver. The ASC must indicate this in the Plan of Correction by checking the waiver box in the Plan of Correction Details. The ASC must submit supporting evidence to substantiate its need for the additional time. Please note: waiver approval is solely at the discretion of CMS. AAAHC will submit the waiver request on behalf of the organization.
Do I have to include a monitoring activity for each item?
Yes. Monitoring activities that describe how and how frequently the organization will ensure that the deficiency remains corrected must be included for each item. Examples may include visual inspections, reports, sampling of clinical records, etc. All monitoring activities must include a specific timeframe.
What if my corrective action is a one-time fix? Do I still need a monitoring activity?
Yes. While this may seem redundant, it is important to ensure that the item remains in compliance. For example, if a deficiency was cited regarding missing labels on an electric panel, the corrective action could be adding proper labels. An appropriate monitoring activity could include a yearly, documented inspection of the labels to ensure they stay attached and legible.
Conferences & Exhibits
- Becker’s Healthcare
October 30–November 2, Chicago, IL - Ohio Association of Ambulatory Surgery Centers (OAASC)
November 13–14, Columbus, OH - Institute for Healthcare Improvement (IHI)
December 8–11, Orlando, FL
1095 Learn
2024 Achieving Accreditation Onsite
December 12–13, Las Vegas, NV
To learn more, visit/AAnews or click the image below.