Plan of Correction

⚠️ F-880 — Infection Prevention & Control

FacilityKit

CMS Form 2567

42 CFR § 483.80

Facility Name

Provider Number (CCN)

Survey Date

Director of Nursing

Infection Preventionist

PoC Due Date

📋 About This Citation — F-880 (42 CFR § 483.80)

What surveyors cite: The facility must establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Common triggers include: inadequate hand hygiene documentation, PPE compliance gaps, failure to follow standard precautions, insufficient infection surveillance, or absent/incomplete IPCP policies.

📄 Deficiency Details (from your Statement of Deficiencies)

Tag Number

Scope & Severity (A–L)

Summary of Deficiency Finding (copy from CMS-2567)

Resident(s) / Staff Affected (if applicable)

Immediate Corrective Actions

Actions taken to resolve the deficiency for the affected resident(s) and to protect others from the same hazard

Immediate Action for Cited Resident(s) / Situation

Action Taken (describe specifically what was done)

Responsible Party

Date Completed

Verified By

Audit of Other Residents / Areas for Same Deficiency

Scope of Audit Conducted (who was reviewed, areas inspected)

Audit Findings

Date Completed

Auditor Name/Title

Staff Re-Education / In-Service Training

Education Topics Covered (e.g., hand hygiene, PPE donning/doffing, standard precautions)

Staff Groups Trained

Training Completed By

Completion Date

PPE Supplies / Environmental Corrections

Actions Taken (e.g., restocked PPE, repaired hand hygiene stations, updated signage)

Responsible Party

Completion Date

Verified By

Systemic Changes to Prevent Recurrence

Policy, procedure, or operational changes made to prevent the same deficiency from recurring

Policy / Procedure Revision or Creation

Policy/Procedure Changed or Created (describe)

Policy Number/Title

Effective Date

Approved By

IPCP Program Updates

Changes to the Infection Prevention and Control Program (surveillance methods, reporting protocols, isolation procedures, etc.)

Infection Preventionist

Implementation Date

Reviewed By

Facility-Wide Communication

How were changes communicated to all staff, contractors, and volunteers?

Communication Method

Date Communicated

Communicated By

Ongoing Monitoring Plan

How will you ensure the problem stays corrected? Must describe specific audits, frequency, and who is responsible

Monitoring Activity

Frequency

Responsible Party

Reporting To

Hand hygiene compliance audits (direct observation of staff technique)

PPE availability checks (all isolation rooms and nursing stations)

Infection surveillance data review (HAI rates, outbreak tracking)

Staff competency / education completion rate review

IPCP policy compliance audit

QAPI Review: When will monitoring results be reported to the QAPI committee?

Responsible Parties & Oversight

Identify the individual(s) accountable for implementation, monitoring, and reporting

Primary Responsible Party

Title

Phone / Contact

Secondary Responsible Party

Title

Monitoring Start Date

Escalation Protocol: If monitoring reveals recurring non-compliance, describe the escalation process

Completion Dates

All dates must be within the 10-day submission window unless a specific extension is granted

All corrective actions fully implemented by:

Initial monitoring period ends:

QAPI committee review of monitoring results:

PoC submission date to State Survey Agency:

Administrator Certification

Required — the Nursing Home Administrator must sign certifying this PoC is accurate and will be implemented

Administrator Name (print)

NHA License Number

Administrator Signature

Date Signed

Director of Nursing Signature

Date Signed

Certification: I certify that the foregoing information is true, accurate, and complete and that I, as the authorized responsible party, have read and understand this Plan of Correction and that the facility will implement each item described herein.

Plan of Correction Template
Infection Prevention & Control

Plan of Correction

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