MHA 508 Week 6 Corrective Action Plan Example

A Silenced Door Alarm and Six Unsupported Codes: Corrective Action Plans for an Immediate Jeopardy Citation and a Medicare Overpayment

[Student Name]

University of Phoenix

MHA/508: The Regulatory Environment in Health Care

Week 6 Assignment

[Instructor Name]

[Date]

The nursing facility operator, both events, the investigations and corrective actions are composites written for a model paper; legal requirements, national citation data and research findings come from the sources cited.

In its final quarter of the year, a composite nonprofit operator of fourteen Pennsylvania nursing buildings faced two compliance failures within a month. At one building, a resident with dementia walked out of a side door on a Sunday afternoon. At three others, an audit had found Medicare assessments coded with diagnoses the records did not support. This paper presents a corrective action plan for each and explains the obligations that shaped them.

Event One: The Door

At 2:15 on a Sunday afternoon, a resident with advanced dementia and a known history of exit-seeking left through a side door near the dining room. The door had a delayed-egress alarm, but the alarm had been silenced that morning by a maintenance contractor who found it sounding repeatedly and could not locate the fault. A neighbor found the resident 40 minutes later, a quarter mile away near a road, cold but unhurt, and called the facility.

Immediate Protection

The charge nurse assessed the resident, notified the physician and family and started one-to-one supervision. The administrator reported the incident to the state survey agency as required. Maintenance restored the alarm within the hour, and staff checked every exit door in the building.

The Citation

A state surveyor investigated the report two days later and cited the building for failing to provide adequate supervision to prevent accidents, at the immediate jeopardy level, because the failure was likely to cause serious harm. Nationally, accident and supervision failures are the second most frequently cited deficiency, and about 2.3% of all nursing home health citations reach the immediate jeopardy level (Centers for Medicare & Medicaid Services, 2026b).

The Removal Plan

Immediate jeopardy requires the facility to show that the danger has been removed before surveyors leave. The building's removal plan, accepted the same day, included functioning alarms on every exit tested daily, reassessment of every resident's elopement risk, updated care plans and photographs of at-risk residents at each station, and education for all staff on the shift about responding to alarms.

Root Causes of the Elopement

The root cause team, led by the director of nursing with a maintenance supervisor and an outside quality nurse, asked why the resident could leave. Four causes emerged. Contractors could silence alarms without notifying nursing. No one owned a daily test of door alarms. The resident's care plan listed exit-seeking but no specific interventions after she had adjusted to a new room. And weekend staffing left one aide covering the dining area and a hallway.

Ranking the Actions

Research on root cause analysis warns against weak fixes. An analysis of 227 root cause investigations with 1,137 recommendations found only 8% of recommendations were strong, while 48% were weak, and training and policy revisions were the most common types; 72% of investigations made no strong recommendation at all (Hibbert et al., 2018). Retraining is the action most often chosen and least likely to prevent the next event.

The Plan of Correction

The plan of correction, submitted within the required time, used stronger actions first. Door alarms were rewired so they cannot be silenced without a key held by the nursing supervisor, with an automatic page to the supervisor whenever an alarm is bypassed. A daily door test is logged electronically and checked by the administrator. Contractor work on doors now requires a nursing sign-off. Weekend staffing added an aide for the dining and hallway area. Education supported these changes rather than replacing them.

Measuring the Fix

Measures include daily door test completion, alarm bypass pages and response times, elopement attempts and successful exits and care plan audits for residents at risk. The building's quality committee reviews them weekly for three months, then monthly.

Event Two: The Overpayments

The operator's coding audit had found six diagnoses in Medicare assessments that the records did not support, all coded after a bonus tied to case mix began. The unsupported codes raised the daily payment for the affected stays.

When an Overpayment Is Identified

Federal rules require a person who has received an overpayment to report and return it within 60 days after it is identified, and define identification using the knowledge standard of the False Claims Act. When a provider is still looking, promptly and honestly, for other overpayments that share the same cause, the clock stops until the investigation concludes or 180 days pass, whichever comes first (Centers for Medicare & Medicaid Services, 2026a).

Investigating the Scope

The compliance officer treated the six codes as the start of an investigation. An outside firm reviewed every Medicare assessment at all fourteen buildings since the bonus began, 1,240 assessments, and found 31 more unsupported diagnoses at five buildings, along with 22 missed diagnoses that had been underpaid.

Calculating and Returning

The finance team recalculated payment for each affected stay. Overpayments were reported and returned through the Medicare contractor's voluntary refund process within the suspended deadline, with documentation of the investigation. Counsel reviewed whether the facts called for OIG's self-disclosure protocol and concluded that, with no evidence of intent, the contractor refund process was appropriate.

Root Causes of the Overpayments

The root causes were the incentive that tied administrator pay to case mix, one-directional chart reviews looking only for added diagnoses and no second review of high-paying codes before submission.

Corrective Actions for Coding

The strongest action was removing the incentive, done months earlier. Others followed: a second-level review of any assessment in the top payment groups before submission, chart reviews that check for unsupported as well as missed diagnoses and an annual external coding audit.

Communicating With the Family

The administrator met the resident's son the evening of the elopement, explained what had happened and what the building was doing, and followed up after the plan of correction was accepted. He asked whether other residents were at risk; the administrator described the reassessment of every resident and the new door controls.

Spreading the Lessons

The elopement happened in one building, but the conditions that allowed it might exist in all fourteen. The chief nursing officer ordered the same door alarm review, contractor sign-off and elopement reassessment across the operator within 30 days. Four other buildings found alarms that could be silenced without a key, and all were rewired. Spreading corrective actions across sites turns one building's citation into protection for every resident.

Governance Oversight

The board's quality and compliance committee received both plans, listing owners, dates, measures and results, and will appear on each quarterly report until follow-up audits close them.

Follow-Up Audits

A follow-up audit of exit doors at all fourteen buildings is scheduled for three months and again at a year. A follow-up coding audit will sample assessments six months after the changes.

What the Two Events Share

One event harmed no one by luck; the other cost public money. Both arose from systems that made failure easy: an alarm that anyone could silence and an incentive that rewarded one direction of coding. Both were corrected by changing systems first.

Conclusion

Corrective action begins with protecting residents and meeting legal deadlines, from the survey agency's removal plan to the 60-day overpayment rule. It succeeds only when root causes are found and fixed with strong actions, measured and audited again. By ranking actions by strength rather than defaulting to retraining, and by reporting results to the board until they are proven, the operator turned two failures into lasting changes.

References

Centers for Medicare & Medicaid Services. (2026a). Requirements for reporting and returning of overpayments, 42 C.F.R. § 401.305. Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

Centers for Medicare & Medicaid Services. (2026b). Health deficiencies [Data set]. Provider Data Catalog. https://data.cms.gov/provider-data/dataset/r5ix-sfxw

Hibbert, P. D., Thomas, M. J. W., Deakin, A., Runciman, W. B., Braithwaite, J., Lomax, S., Prescott, J., Gorrie, G., Szczygielski, A., Surwald, T., & Fraser, C. (2018). Are root cause analyses recommendations effective and sustainable? An observational study. International Journal for Quality in Health Care, 30(2), 124-131. https://doi.org/10.1093/intqhc/mzx181