Form CMS-2567 Plan of Correction Template for Hospice Bereavement Deficiencies

What the Plan of Correction Actually Requires

A CMS-2567 citation lands on your desk, and the response is time-sensitive. Check the notice and state survey agency instructions immediately for the applicable submission deadline. The POC is not a promise to do better. A useful framework answers four questions for every cited deficiency and makes the corrective action concrete.

Those four questions are:

1. What corrective action was taken for residents (or patients) affected by the deficiency? This addresses the immediate harm. For a bereavement-specific citation — say, a family that did not receive a documented risk assessment — your POC must state what you did for that specific family, not what you plan to do in general.

2. What systemic change will prevent recurrence? This is the structural fix. If the citation was for generic, non-individualized bereavement care plans, your systemic change might be implementing a mandatory individualization checklist that links specific BRAT domain scores to specific care plan interventions.

3. How will you monitor the corrective action to ensure it holds? Include a monitoring method, its frequency, the responsible person, and a review period that fits the corrective action and the survey agency's instructions.

4. What is the completion date? This date must be realistic and specific. Surveyors will return for a validation survey, and they will check whether what you described actually happened by that date.

Common Bereavement Deficiency Categories and POC Approaches

Deficiency: Incomplete or missing initial bereavement risk assessment. The corrective action for the affected family is straightforward — complete the assessment immediately. The systemic fix requires building the assessment into your admission workflow so it cannot be bypassed. Consider making the BRAT or AAG assessment a required field in your EHR that blocks care plan completion until it is populated. Your monitoring plan: the clinical manager audits every new admission chart within 72 hours for 90 days, documenting compliance rates weekly.

Deficiency: Bereavement care plans are not individualized. The immediate correction: revise the cited care plans to reflect each family's specific risk factors, coping patterns, and support needs. The systemic change: create a care plan builder that requires clinicians to select interventions matched to the risk level identified by the assessment tool. A BRAT Level 2 family gets standard mailings and milestone check-ins. A Level 5 family gets weekly clinical contact and a referral pathway. Document this mapping in your policy and procedure manual. Monitor by pulling five random care plans per week for 90 days and comparing them against their assessments.

Deficiency: No documentation of IDG review of bereavement plans. This is a 42 CFR § 418.56 issue. The IDG must review and update the plan of care every 15 calendar days, and bereavement must be part of that review. Your systemic fix: add a standing bereavement agenda item to every IDG meeting with a required documentation field. Monitor by auditing IDG meeting minutes weekly to confirm the bereavement update appears for every active and recently deceased patient.

Deficiency: Gaps in post-death follow-up documentation. Immediate action: contact the families who fell through the gap and document the outreach. Systemic fix: implement an automated tracking system — or, if manual, a master spreadsheet with milestone dates and completion fields that is reviewed weekly by the bereavement coordinator and monthly by the clinical manager. Monitor by running a monthly reconciliation report comparing deaths to documented follow-up contacts.

POC Writing Mistakes That Lead to Rejection

Being too vague. "Staff will be re-educated on bereavement documentation requirements" is not a systemic change. What specific training? Delivered by whom? On what date? With what competency validation? Surveyors need specificity.

Confusing education with correction. Re-training staff is almost always part of a POC, but it is never sufficient alone. If the system allowed the deficiency to occur, re-training without a structural change just means educated staff will make the same error in the same broken system.

Setting an unrealistic completion date. If your systemic change requires EHR modifications, a 10-day completion date is not credible. Be honest about the timeline. Surveyors would rather see a realistic 60-day implementation plan than a 10-day promise that cannot be kept.

Failing to address every affected patient. If the surveyor cited three specific charts, your POC must address all three — and explain how you identified whether additional patients were also affected.

Using the POC as a Quality Improvement Opportunity

The best-run programs treat a CMS-2567 citation not as a punishment but as a diagnostic tool. The deficiency revealed a gap. The POC is the documented fix. And the monitoring plan, if genuinely implemented, becomes the foundation for an ongoing QAPI initiative around bereavement documentation quality.

The Hospice Worker's Family Bereavement Support Toolkit includes compliance audit checklists and documentation templates aligned with the CoP requirements surveyors cite most frequently — designed to prevent the deficiency before it becomes a citation.