Does Your Plan of Correction Seem Overwhelming to Audit and Maintain?

by Annette Sanders, Senior Consultant on September 28, 2021




Often, after the plan of correction is written, nursing homes struggle with the additional auditing and oversight required for compliance. This typically occurs due to the daily challenges of managing a nursing home.

Let’s be honest, plan of correction auditing and monitoring adds to the daily, weekly, and monthly responsibilities of the leadership team, and because of this plan of correction focus can be easily lost. Independent monitoring of the plan of correction can assist with maintaining that focus and mitigate the risk of repeat deficiencies. That is where LW Consulting, inc. (LWCI) can help!

What is Independent Monitoring?

Independent monitoring is performed by an outside agency that brings expertise in healthcare compliance to the table following the receipt of the 2567. The consultant will facilitate discussions with the leadership team that will review actions taken, results of actions, next steps, barriers, challenges, and time frame for compliance. The consultant will review and provide comments on the plan of correction. The consultant will work on-site and remotely to monitor the progress of goals, level of compliance, compliance gaps, and recommendations for the next steps.

Monitoring actions may include a review of:

  • Residents’ medical records
  • QAPI minutes
  • Incident reports
  • Staff and resident interviews
  • Human Resource records, including personnel files
  • Revised policies and procedures
  • Staff education and training files
  • Attending meetings such as daily stand up, risk meetings, QAPI meetings
  • Training materials
  • Assistant with developing and revising policies and procedures
  • Audit checklist
  • Staff Observations

How Can Independent Monitoring Benefit Your Organization?

  • Demonstrates commitment to the Department of Health (DOH) regarding regulatory compliance.
  • Provides assistance in avoiding repeat deficiencies and possible civil money penalties.
  • Helps to develop a plan to monitor activities based on the plan of correction.
  • Administers continued outside focus on the plan of correction auditing and monitoring.
  • Promotes organizations to be proactive instead of reactive by identifying compliance gaps prior to the survey.
  • Improves quality of care, which will lead to enhanced resident satisfaction.
  • Improves quality measures and your 5-star rating.

LWCI’s experts can assist your organization with independent monitoring of the plan of correction and managing an ongoing compliance process.


For more information, contact Patty Klinefelter at 540-686-1311 or email 

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Topics: Compliance, Healthcare Consulting