MDH Addresses Questions on Directed Plans of Correction to Nursing Homes

Posted on February 3, 2021 by Jonathan Lips

Over the past six months, the Minnesota Department of Health (MDH) has been issuing “Directed Plans of Correction” (DPOC) to nursing homes cited for deficient infection control practices. Care centers have raised questions and concerns about the DPOC process, and we worked recently with MDH to clarify two key issues.

Background
Noting weaknesses in nursing home infection control practices, CMS announced enhanced enforcement actions in June 2020 for deficiencies associated with infection control requirements. Among other things, the CMS memo established that all facilities cited at D or above for requirements at F880 would have to complete a DPOC.

A DPOC is an enforcement remedy – just like a civil money penalty, or denial of payment. It identifies specific actions a facility must take in response to a deficiency, which may include policy and procedure changes, education of staff, and so on. CMS may impose a DPOC in combination with other remedies.

As a result of the CMS memo, each time MDH cites a facility for F880 it will issue both a Statement of Deficiencies and a Directed Plan of Correction. MDH will provide a letter notifying the facility of the remedy and referring to the DPOC as an attachment. Click to see an example of a DPOC issued recently to a LeadingAge MN member that MDH cited in relation to cohorting practices.

Frequently-Asked Questions: Are All DPOCs the Same?
DPOCs have elements in common, but each one should be tailored to the specific deficient practices MDH has identified.  MDH has created a template for Unit Supervisors to work from. The template is comprehensive, covering many commonly cited infection control issues, and the idea is that Unit Supervisors will use it to create a DPOC that is customized to the facility’s situation, including the specific deficient practices being cited and the scope and severity of the tag.

Based on examples shared by LeadingAge MN members, it appears MDH in some cases has issued DPOCs that are broader than necessary.  Suppose, for example, that MDH conducts a Focused Infection Control survey and cites the facility only for deficient practices relating to cohorting residents/ transmission-based precautions.  In this case, MDH should issue a DPOC that requires specific actions relating to cohorting, but it does not also need to require the facility to take actions relating to, say, proper donning and doffing of PPE, since no deficiency was noted in that area.

In some cases, it will be appropriate for MDH to issue a comprehensive DPOC covering a wide range of issue areas, but this will not always be true. If you receive a DPOC, read it carefully, consider how it connects to the issues identified in your 2567, and ask questions of your Unit Supervisor until you understand what is expected and why.

Frequently-Asked Question: What Do I Have to Do and When?
Many providers that have received DPOCs have been unclear on what they have to submit to MDH and when. This confusion has arisen partly from how DPOCs are written, and partly because MDH Unit Supervisors have not all explained the DPOC process in the same way.

If your facility receives a DPOC, you must do two things:

1. You must submit a complete Plan of Correction for all cited deficiencies (including F880), within 10 days after you receive the 2567. This is the same practice you have always followed in the past. Imposition of the DPOC does not replace the requirement to take this step.
2. In addition, you must submit documentation to evidence that you have successfully completed the actions identified in the Directed Plan of Correction. The DPOC will include a checklist of the documents you are required to submit. There is no specific deadline for submitting this additional documentation. However, you should submit it as soon as practicable, because MDH will not approve a revisit (needed to return the facility to a state of substantial compliance) until it receives confirmation that you have completed the DPOC.

Two issues have created confusion about the DPOC documentation requirement:

• One is that the DPOC document and enforcement letter say the DPOC will be effective 15 calendar days from the date of the enforcement letter. This does not mean the facility must complete and document all of the required actions within 15 days. Rather, the DPOC includes that language only to notify the facility when the remedy takes effect. In most cases, MDH/CMS gives some advance notice before imposing a remedy, and that is what’s happening here. [Think of a facility receiving advance notice that discretionary denial of payment for new admissions may take effect on a certain date in the future, as another example of this.]
• The other is that facilities have received different instructions from different Unit Supervisors. Some supervisors have accepted a facility’s Plan of Correction (i.e. the “regular” POC that is due within 10 days), knowing that documentation showing completion of the DPOC items will be submitted separately at a later date. But in other cases, a supervisor has explained that a facility must submit documentation showing successful completion of the DPOC before MDH can accept the facility’s Plan of Correction. This would create a problem, because it often won’t be possible to complete the directed plan within 10 days, meaning the facility would not be able to submit its POC in a timely way.

We talked to MDH about this and confirmed that a facility may tackle these actions – submitting a POC and submitting documentation to evidence successful completion of the directed plan – as two steps. A facility must do both, but you may submit the POC within the required 10 days, and then go back into ePOC and submit the required documentation separately at a later date.

MDH described a technical issue that explains some of the confusion and miscommunication. The way the current ePOC system is programmed, a facility cannot upload additional documents after MDH formally accepts the Plan of Correction through the EPOC system.

In order to circumvent this issue, MDH has developed the following plan: The supervisor will reject the POC for F880 and include in the comment section of the ePOC system that the POC has been accepted but awaiting additional documents to complete DPOC process. This will leave the portal open for the facility to upload the final DPOC documents for review.

When adding DPOC attachments to the ePOC system, the software doesn’t have a limit to the number of attachments in ePOC, but no single attachment can be greater than 4MB. Click for step by step instructions on how to attach documents in ePOC.

We are here to help!  If you have any questions regarding Directed Plans of Correction, please reach out to Jonathan Lips (jlips@leadingagemn.org) or Kari Everson (keverson@leadingagemn.org).