Plan of correction: what CMS requires and how to write one that is accepted
Short answer
A plan of correction is the facility's written answer to the deficiencies on Form CMS-2567. It is due within 10 calendar days of receiving the form. A nursing home plan must cover residents affected, residents at risk, systemic change, monitoring and completion dates. It is the facility's allegation of compliance.
- Form
- CMS-2567, Statement of Deficiencies and Plan of Correction
- Due
- 10 calendar days from receipt of the CMS-2567 (nursing homes and ASCs)
- Nursing home elements
- Residents affected, residents at risk, systemic change, monitoring, completion dates
- ASC elements
- Seven items, including monitoring, completion dates and the responsible person's title
- Signature
- Nursing home: facility official, usually the administrator. ASC: administrator, page 1
- Not required
- Nursing home deficiencies at scope and severity level A, and past noncompliance
- If no acceptable plan
- State recommends remedies; termination required if a nursing home never submits one
Applies to: Medicare- and Medicaid-certified nursing homes · Medicare-certified ambulatory surgical centers
What is a plan of correction?
Form CMS-2567 records a survey's findings, and the facility uses it to answer them. The plan of correction (POC) says how and when the facility will correct each deficiency (a rule it did not meet). CMS calls it the facility's allegation of compliance. Without one, CMS and the state cannot verify compliance.
Nursing homes follow 42 CFR 488.402(d), applied through Chapter 7 of the State Operations Manual. ASCs follow Appendix L. See the plan of correction glossary entry and what to put in a plan of correction.
What are the deadlines?
| Step | Nursing homes | Ambulatory surgery centers |
|---|---|---|
| State sends Form CMS-2567 | By the 10th working day after the last day of the survey | Prepared and mailed within 10 working days |
| Plan of correction due | 10 calendar days after the facility receives the 2567 | 10 calendar days after receiving the written statement of deficiencies |
| Disputing findings | Written request for informal dispute resolution within the same 10 calendar days | Record objections on the 2567 and choose one of three options below |
| If no acceptable plan arrives | State recommends remedies. CMS rules require termination if a nursing home never submits an acceptable plan | Failure to submit an acceptable plan may result in termination of the supplier agreement |
For ASCs, CMS says the 2567 is made public no later than 90 calendar days after the survey.
What are the five elements for a nursing home?
An acceptable nursing home plan must do all five of these:
- Say how corrective action will be done for residents affected by the deficient practice.
- Say how the facility will find other residents who could be affected by the same deficient practice.
- Say what measures or systemic changes will keep the deficient practice from happening again.
- Say how the facility will monitor its performance to make sure solutions last.
- Give dates when corrective action will be completed. The state must accept them.
No plan is needed for deficiencies at scope and severity level A, or for past noncompliance corrected when cited.
What must an ASC plan of correction contain?
- The action that will correct each specific deficiency.
- How the actions will improve the processes that led to the deficiency.
- The procedure for putting the actions in place.
- A completion date for each deficiency.
- Monitoring and tracking to confirm the plan works and compliance continues.
- The title of the person responsible for carrying out the plan.
- The administrator's signature and date on page 1 of Form CMS-2567.
An ASC has three options. One: accept the deficiencies and submit a plan. Two: record objections and still submit a plan. Three: record objections, skip the plan and submit written arguments and documented evidence that the deficiencies are invalid. CMS considers objections to the factual accuracy of findings, not to its judgment on level, extent, scope or severity. If CMS disagrees with the objections, an acceptable plan is still required.
How do you write a plan that gets accepted?
The first two steps follow CMS's published expectations. The rest is our practical advice.
- Answer each deficiency on its ownMatch each part of the plan to the tag or requirement cited. An unacceptable plan is returned for revision.
- Fix the system, not only the people involvedCMS tells surveyors to ask if corrective action fixes underlying, systemic causes and was evaluated for effectiveness.
- Reach beyond the exampleNursing homes must say how they will find other residents at risk. ASCs should do the same for other cases and rooms.
- Write monitoring that can be auditedName what you will measure, how often, who collects it and where results go, such as the QAA committee.
- Set dates you can meetThe state must accept the dates. Keep dated evidence for each fix.
- Name an owner by title and signUse a title, not only a name. The administrator or another authorized official signs.
| Element | Weak wording | Stronger wording |
|---|---|---|
| Monitoring | The director of nursing will monitor. | The director of nursing audits 10 records a week for 8 weeks, then monthly for 3 months. Results go to the QAA committee, which acts if the target is missed. |
| Other residents | No other residents were affected. | Records of all residents with the same risk were reviewed within 7 days, and each was reassessed. |
| Completion date | Ongoing. | Completed by the stated date. Evidence: revised policy, sign-in sheets, first audit results. |
What happens after you submit?
The state reviews the plan and tells the facility in writing if it is unacceptable. If it is acceptable, notice may come by phone or email. The facility is still accountable for its own compliance, even if notice is late.
A revisit may be on site or a paper review. The date of substantial compliance depends first on credible written evidence for the date you allege. It can be earlier than your plan date if you can prove it. Show when actions happened, how they fixed the noncompliance and how they prevent it from recurring. Surveyors look for proof the plan was carried out. They do not assume that means compliance. See always survey-ready and close corrective actions.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| Identify residents affected and others at risk | Records show who was affected. Analytics group similar events by location, shift and cause to find others at risk. |
| Systemic change that prevents recurrence | Corrective actions come from the investigation and carry an owner, due date and evidence. |
| Monitoring that shows the fix held | Each corrective action has an effectiveness check. Nothing closes until it is verified. |
| Dated evidence for a revisit | The audit trail logs who changed what and when. Compliance packets gather the evidence. |
| Writing, signing and submitting the plan | You write, sign and send the response to your state agency. IncidentKit supplies the records behind it and does not file it. |
Product parts involved: Corrective actions (CAPA), Investigations and RCA, Audit trail, Compliance packets, Analytics. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
How long do we have to submit a plan of correction?
Ten calendar days from the day the facility receives Form CMS-2567, for nursing homes and ASCs. Count calendar days, not working days. A nursing home's written request for informal dispute resolution is due in the same 10 days.
Do we need a plan for every deficiency?
For nursing homes, yes, except deficiencies at scope and severity level A, or past noncompliance already corrected when cited. For ASCs, a written plan is required, and it must address each cited deficiency.
Who signs the plan of correction?
Nursing home: a facility official with management authority and responsibility, normally the administrator. The director of nursing or a corporate representative may sign instead. ASC: the administrator signs and dates page 1. Some states use electronic signatures.
What if the state says our plan is not acceptable?
The state tells you in writing, and the plan goes back for revision. If no acceptable plan arrives in 10 days, the state recommends remedies, which can take effect once notice requirements are met. CMS rules require termination of a nursing home that never submits one.
Is the plan of correction public?
For ASCs, yes. CMS makes Form CMS-2567 with the plan public no later than 90 calendar days after the survey. Resident and patient names are not used. Surveyors use identifiers instead.
Sources
- CMS State Operations Manual, Chapter 7, sections 7316 and 7317: key dates and acceptable plan of correction (Rev. 244)
- CMS State Operations Manual, Appendix L: ASC exit conference, acceptable plan of correction and options
- CMS State Operations Manual, Appendix PP: plan of correction elements restated from Chapter 7, section 7317
- CMS, Nursing homes: regulations and guidance
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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