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This document outlines deficiencies identified during a health care quality survey and includes a plan of correction by the provider, detailing required actions to address these deficiencies.
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How to fill out STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

01
Read the instructions provided with the Statement of Deficiencies and Plan of Correction (SOPC).
02
Identify and document each deficiency noted during the inspection or audit.
03
For each deficiency, provide a detailed plan of correction outlining the steps to address the issue.
04
Assign responsible parties for each step in the plan of correction.
05
Set a timeline for completion of each corrective action.
06
Ensure that the plan is realistic and achievable within the set timeframe.
07
Review the completed SOPC for accuracy and completeness before submission.
08
Submit the SOPC to the relevant authority as per the guidelines provided.

Who needs STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

01
Healthcare facilities undergoing inspections or audits.
02
Providers who need to demonstrate compliance with regulations.
03
Organizations seeking accreditation or certification.
04
Any entity required to address deficiencies identified by regulating bodies.
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There are three scope levels assigned to a deficiency: isolated, pattern, or widespread. The survey agency determines the scope and severity levels for each deficiency cited on a survey.
Element 1: How the corrective action will be accomplished for identified affected individuals. Element 2: How will other individuals with the potential to be affected or in similar situations be identified and protected. Element 3: What systemic changes will ensure that the deficient practice will not recur.
There are three scope levels assigned to a deficiency: isolated, pattern, or widespread. The survey agency determines the scope and severity levels for each deficiency cited on a survey.
An acceptable Plan of Correction will include both immediate corrective actions to correct the violation and long-term quality improvement actions, with each element including who is responsible, when it will be done, and what action has been or will be taken.
A facility is not required to submit a plan of correction when it has deficiencies that are isolated and have a potential for minimal harm, but no actual harm has occurred.
In all cases of immediate jeopardy, the provider agreement must be terminated by CMS or State Medicaid Agency no later than 23 calendar days from the last day of the survey if the immediate jeopardy is not removed.
To write a Statement of Deficiencies, three elements must be completed: • Gather enough strong evidence. Differentiate finding and deficient practice or noncompliance. Based on a regulation/requirement, recognize what the entity failed to do. Don't wait until near the end of the survey.

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The Statement of Deficiencies and Plan of Correction is a document used by healthcare facilities to address and outline deficiencies identified during inspections or surveys. It details the areas where compliance fails and presents a plan to correct these deficiencies.
Healthcare facilities that are subject to inspections, such as nursing homes, hospitals, and other licensed care providers, are typically required to file a Statement of Deficiencies and Plan of Correction when deficiencies are noted during regulatory surveys.
To fill out a Statement of Deficiencies and Plan of Correction, facilities should identify each deficiency, provide a detailed description, and outline specific steps they will take to resolve the issues. Each plan should include timelines and responsible parties for completion.
The purpose of the Statement of Deficiencies and Plan of Correction is to ensure that healthcare facilities are compliant with required regulations and standards. It serves as a formal commitment to address identified issues and improve the quality of care provided to patients.
The information that must be reported includes specific deficiencies noted during inspections, a description of corrective actions planned, timelines for remediation, and the individuals responsible for implementing the corrective actions.
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