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Hospital Accreditation

5 Tips for Developing Corrective Action Plans
Posted by on 12/5/2023 10:00:00 AM
Responding to the survey report provided by your Accrediting Organization (AO) or the CMS Statement of Deficiencies – more commonly known as the infamous “2567”, can be quite overwhelming. For additional pressure, the clock starts ticking as soon as the deficiency report arrives. For CMS and most AO’, the hospital has ten days to respond with corrective action plans addressing all the deficiencies found during the survey.
Many hospitals make the mistake of waiting for the AO survey report or the CMS-2567 to arrive before starting to develop corrective action plans. Waiting creates haste and can result in overlooked deficiencies and incomplete action plans that may not be accepted. Here’s a few tips to ease the burden and get your corrective action plan easily accepted on the first attempt.
  1. Start during survey!
    Assign comprehensive note takers to each surveyor. At the end of each survey day, gather your team and discuss the day’s events. Listen closely to surveyor feedback during the exit conference or morning briefings – most surveyors will communicate and explain deficiencies. Now is the best time to initiate action plans by incorporating any immediate corrective actions that may have occurred during the survey. Once the survey has concluded, gather drafted action plans which may need some fine tuning but that’s much easier than starting from scratch.
  2. Include dates and watch those deadlines!
    When writing corrective action plans – it’s all about the facts! Action plans must stay on track and to do so, deadlines are a must. Keep track of dates. Note at least the date that the overall corrective action plan will be complete, along with implementation dates for key steps, e.g., include the date the policy or form was revised, when staff education was implemented, the date vendors were contacted to schedule work, etc.
  3. Each deficiency requires a corrective action plan.
    Moved that bed or WOW from the egress during the survey? Maybe you fixed a lock or adjusted latches on a door – It’s great that immediate corrective action was taken but the finding doesn’t go away and will show up in your deficiency report. Although corrected while surveyors were onsite, non-compliance was still found, and each deficiency must have its own corrective action plan.
  4. Address only what is written in the deficiency statement.
    You want to focus on the finding and not respond to comments made during the survey or extraneous issues. If needed, plan to revisit related issue(s) with team members after submission.
  5. Prepare documentation.
    The actions outlined in your corrective action plan will undergo a review process which can lead to the AO or CMS requesting confirmation the corrective action plan was implemented. Most definitely, in the case of condition-level deficiencies, a surveyor will be returning to conduct a follow-up survey within 45 days, following the last day of the survey. The purpose of the follow-up survey is to confirm corrective action plans were implemented. You want to have all corrective action plan documentation related to condition-level deficiencies in a binder and ready to hand to the follow-up surveyor upon arrival. Prepared documentation can get them out the door faster (with less time to stumble onto other deficiencies.)
  1. Center for Improvement in Healthcare Quality. (June, 2023). Accreditation Standards for Hospitals. Retrieved from
  2. Center for Medicare and Medicaid Services. (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. Retrieved from
  3. Curtis, T. (2023, September 27). The CMS 2567: Writing Plans of Correction. [Conference Presentation]. 2023 Accreditation and Regulatory Summit. Center for Improvement in Healthcare Quality.
  4. Department of Health & Human Services. Centers for Medicare and Medicaid Services. Statement of Deficiencies and Plan of Corrections Form 2567.
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