The Division of Quality Assurance (DQA) issues electronic Statements of Deficiencies (e-SOD) via email to health care providers. The provider can use an electronic Plan of Correction (e-POC) form to submit information to DQA. Below we offer details and instructions on the e-SOD/e-POC process.
Most providers will complete the Provider Agreement form during an on-site survey. At that time, the provider's authorized representative agrees to accept the results of a survey including electronic Statements of Deficiency (SODs). Providers can select the email address where the SODs are sent. Providers also agree to submit Plans of Correction (POCs).
DHS has established a secure file sharing site using Dropbox.com which can be used to easily and securely transfer large or sensitive data files.
DQA is transitioning to use Dropbox to send the provider their e-SOD and attachments.
You will need a Dropbox account to access shared files. DQA will email information about setting up your account. You should use an individual email address and avoid generic or shared email addresses when creating the account.
DQA's email will identify the shared documents. It also will include instructions for saving these files and for returning the required documents to DQA. The provider must reply to DQA to confirm receipt.
The SOD's effective date of service is the date DQA emails the authorized representative identified on the Provider Agreement form. Files DQA may send include:
- Statement of Deficiency Cover Letter: A letter from DQA with recent survey information.
- SODs: Form CMS-2567 (PDF) identifies each issued citation. Federal and state citations are issued on separate SODs. The first page of the federal SOD must be signed, dated, scanned, and emailed back to DQA. Or you may fax it to DQA.
- POC Form (F-00344): The provider uses this form to document their POC for each citation listed on the SOD.
- Attestation of Correction Form (F-02172): Only for certified residential care apartment complexes (RCACs) when the provider corrects cited deficiencies. The provider uses this form to attest that all deficiencies have been or will be corrected within 45 days of receipt of the notice.
- Identifier Key (F-62552): Includes confidential information like names of residents, patients, clients, staff, complainants, and family members. Important note: Do not email this document back to DQA.
You must save each of these attachments to your computer.
- Open the saved POC Form (F-00344) in Word. Do not alter the format of this form. Use Word or other word processing software to enter information (do not handwrite).
- Enter the respective tag number(s) as listed in the first column (x4) of the SOD in the first column (x4) of the e-POC form.
- In the second column, Provider's POC, describe the corrective action(s) that has or will be taken to address this referenced deficient practice.
- Enter the completion date for that corrective action in the third column (x5).
- Complete this process for all tags issued, entering them in the same order as they are listed on the SOD and using one row per tag.
- Save and close the document.
If multiple SODs are issued, a separate POC Form (F-00344) should be completed for each SOD.
Save regularly throughout POC entry.
For certified RCACs when a statement of deficiency with violations is issued, instead of the traditional POC, the certified RCAC will submit a plan of correction via attestation using an Attestation of Correction form, F-02172.
- Open the saved Attestation of Correction Form (F-02172) in Word. Do not alter the format of the form. Use Word or other word processing software to enter information.
- Enter the name of the facility on the Attestation of Correction form, F-02172 to attest that all deficiencies have been or will be corrected within 45 days of receipt of the notice.
- Save and close the document.
- Open and reply to the email sent by DQA containing the e-SOD.
- Attach the completed e-POC form or Attestation of Correction form. (Do not fax this document.)
- For federal SODs only, if issued a SOD containing federal deficiencies (including Life Safety Code), print only page one of the SOD and sign and date where indicated. Then, scan and attach the signed page along with the e-POC form. Or you can fax the signed page to DQA.
- Send the email.
Refer to the SOD letter for the required elements in your POC.
The POC must describe the corrective action the provider will take to address the cited violation or deficiency. Although providers may acknowledge that they disagree with the survey findings, they may not use the POC to malign the surveyors. The POC is a public record. Do not include names of residents, patients, clients, or facility staff.
Listed below are links to survey guides by provider type. These guides provide information about the survey process including the contents for an acceptable POC:
- Survey Guide: Clinical Laboratories, P-01227 (PDF)
- Survey Guide: Facilities Serving People with Developmental Disabilities, P-63051 (PDF)
- Survey Guide: Home Health and Hospice Licensure and Certification, P-63075 (PDF)
- Survey Guide: Hospitals, Critical Access Hospitals, and Other Health Services Providers, P-62033 (PDF)
- Survey Guide: Long-Term Care Facilities, P-62014 (PDF)
- Survey Guide: Behavioral Health Certification for Mental Health and Substance Abuse Services, P-63174 (PDF)
- Survey Guide: Personal Care Agency, P-00191 (PDF)
MAXIMUS Federal conducts informal dispute resolution (IDR) and independent IDR. There is no charge for desk review. The fee for telephone review is $100. Learn more with the following links:
- Informal Dispute Resolution for Nursing Homes and Facilities Serving People with Developmental Disabilities (FDD), P-01856 (PDF)
- Independent Informal Dispute Resolution for Federally Certified Nursing Homes, P-01855 (PDF)
- Informal Dispute Resolution for Medicare-Certified Home Health Agencies, P-01857 (PDF)
SODs and POCs will be available to the public, even for providers who choose not to participate in the e-SOD/e-POC process. Survey information and other provider demographic information can be accessed using the DQA Provider Search.
For help with this process, contact DQA:
- Email email@example.com
- Phone 608-266-8481
- Fax 608-267-0352
Mailing address:DHS Division of Quality AssuranceP.O. Box 2969Madison, WI 53701-2969