Top 5 2021 Colorado Home Care w/ full Plans of Correction & Tools

Included is the list of the Top 5 deficiencies that have been cited in 2021: Quality Management Program, Client File Incomplete, Staff File Incomplete, Staff Credential Check and Supervisory Visits. Each deficiency then has a full plan of correction that meets the required 5 elements for an acceptable plan of correction so it will be accepted by CDPHE the first time. After the plans of correction are templates of the most commonly used tools for a plan of correction: Staff Education Form and Audit Tool. Using these tools, along with the plan of correction, will demonstrate to the survey reviewer that you have corrected any issues and good to be put back in compliance. 

In 2021, these 5 deficiencies were issued 211 TIMES!! Wow! If you have survey pending, take a look at the POC to complete now and avoid a deficiency!

#1 -Quality Management Program

Deficiency: The agency failed to maintain a QMP that included documentation of scheduled meetings that identified issues, investigations, tracking, trending, corrective measures, outcomes, and feedback from the governing body.

#2 - Client File Incomplete

Deficiency: Based on interviews and record review, the agency failed to have complete and accurate records for 1 of 3 consumers whose records were reviewed (Consumers #1). The agency failed to ensure Consumer #1's record contained evidence of visits conducted. Review of Consumer #1's care plan revealed Consumer #1 was to receive services daily, seven days per week, for five hours each visit. Review of the Care Logs (completed services) dated 9/1 through 9/30 revealed visits were not conducted on 9/3, 9/6 and 9/27. This was a total of 3 visits not conducted.

#3 - Staff File Incomplete

Deficiency: Based on record review and interview, the agency failed to ensure all agency employees had complete personnel records in 4 of 4 personnel records reviewed (Employees #1, #2, #3, and #4). The agency failed to complete performance evaluations on agency personnel.

#4 - Staff Credential Check

Deficiency: Based on interview and record review, the agency failed to verify with the Department of Regulatory Agencies (DORA) whether 2 of 5 employees whose personnel records reviewed (Employee #4 and #6) held a license, registration or certification and it was in good standing prior to hire.

#5 - Supervisory Visits Not Done

Deficiency: Based on interview and record review, the agency failed to provide documentation of an on-site supervision visit at a minimum every three (3) months for 1 of 3 employees (Employee #1) after review of personnel records.

This downloadable tool will come in handy before, during or after a survey from CDPHE. Use this as your actual Plan of Correction or a guide to help put your POC together quicker.