What to know: Chapter 7 – Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities of the State Operations Manual (SOM) outlines how surveyors will verify a facility’s compliance and plan of correction following a survey.

• When verifying compliance during a revisit, the state survey agency will request/review credible evidence for validation that the plan of correction was implemented. Section 7317.2 of the SOM specifies that both paper reviews and onsite reviews are considered revisits.
• The plan of correction serves as the facility’s allegation of compliance in non-immediate jeopardy cases.

Why it matters: Substantial compliance cannot be certified, and any remedies imposed cannot be lifted until facility compliance has been verified.

• If you are anticipating an off-site/desk review following your survey, remember that credible evidence to support compliance is just as important as it is for an on-site revisit.

Examples of acceptable evidence of your substantial compliance may include, but are not limited to:

• An invoice or receipt verifying purchases, repairs, etc.
• Sign-in sheets verifying attendance of staff at in-services training. Interviews with more than 1 training participant about training.
• Contact with resident council, e.g., when dignity issues are involved

How it works: Once you have submitted your plan of correction you will receive a notice from the OLC when it has been accepted. The survey representative will identify what information you need to submit for review before substantial compliance can be verified and ask that it be sent electronically for review.

• The more complete the plan of correction is, the more organized the credible evidence is, and the timelier that you submit the requested information, the sooner you will have verification of substantial compliance