We Were Cited. What Do We Do Before We Write the Plan of Correction?
Reviewed October 2026
In IHS's reading, before you write the plan, do five things in order: confirm the issuer's response deadline and format while acting on any immediate safety risk, investigate repeat findings, group findings by cause, assign an owner to each, and define the evidence that will show each correction worked.
For providers covered by 42 CFR 488.28, CMS's State Operations Manual (Chapter 2, section 2728B, marked Rev. 1, 05-21-04) says an acceptable plan of correction must contain the plan for correcting the deficiency, which should address the process that led to it, how the fix will be implemented, how it will be monitored to stay effective, and the title of the person responsible. It must also state the expected completion date. The Joint Commission's Evidence of Standards Compliance instructions likewise ask for one accountable person by title, the date the corrections were finished, and a process that detects and monitors recurrence.
In IHS's reading, building every response on those five parts (cause, action, owner, date, monitoring) fits the frameworks reviewed here, though each issuer decides what it accepts. The five steps above are an order for organizing work before drafting a plan, not a universal regulatory sequence. This page does not cover URAC's response requirements. For a URAC finding, check URAC's written decision and your accreditation agreement for any instructions on what the response must contain and when it is due, and use this page to organize the supporting work. CARF's public pages and NCQA's 2021 health plan policy update, the documents reviewed here, give timing (a CARF Quality Improvement Plan within 90 days after notice of the accreditation decision; an NCQA corrective action plan within 30 calendar days of receiving final accreditation status when must-pass thresholds are missed, in that 2021 program-year document) but list no required plan fields.
What do we check before writing anything?
In IHS's reading, first establish which response instructions apply to this survey and preserve the event that starts the clock. Record the issuer, surveyed program, decision, report receipt or posting date, due date, and required submission method. Separate the response deadline from the correction deadline. For a provider covered by 42 CFR 488.28, the manual's 10 calendar days runs from receipt of Form CMS-2567.
For ACHC hospital accreditation, the published guidance directs hospitals to use Compass and allows 10 calendar days after receiving the report to submit the plan of correction. The same guidance sets corrective-action completion within 60 calendar days of the last survey day. Both are hospital-program instructions, not deadlines for every ACHC service or state survey. ACHC's Specialty Pharmacy process document (revised April 2023) separately says a plan of correction goes on ACHC's template and names the standard out of compliance, the corrective action, an implementation date, the title of the person responsible, and the process for continued compliance.
Is there a federal deadline to submit a plan?
Not in 42 CFR 488.28. CMS's manual does set one. Section 488.28(d) says a provider or supplier is ordinarily expected to take the steps needed to achieve compliance within 60 days of being notified of the deficiencies, and the State survey agency may recommend more time in individual situations. In IHS's reading, that is a correction timeframe, not a deadline for submitting a plan. For the same providers, CMS's State Operations Manual (Chapter 2, section 2728B) tells the provider to return Form CMS-2567, which carries the plan of correction, to the State survey agency within 10 calendar days of receipt. The regulation does not apply to four provider types: skilled nursing facilities, nursing facilities, home health agencies, and hospice programs.
Section 488.28(a) and (b) let a covered provider or supplier with deficiencies in one or more standards of its applicable conditions keep participating only with an acceptable plan of correction, and only if the deficiencies neither jeopardize patient health and safety nor seriously limit its capacity to render adequate care; CMS may shorten compliance time for immediate jeopardy. Section 488.30 sets user fees for revisit surveys, which evaluate whether cited deficiencies were corrected and can be offsite or onsite; it does not govern plan acceptance.
Which findings need action before the plan is finished?
In IHS's reading, actual or likely serious harm takes priority over routine drafting, even while the compliance lead establishes the response clock. Route the finding to the responsible clinical or operational leader for protective action and document who else may remain exposed.
CMS Appendix Q identifies three immediate-jeopardy components: regulatory noncompliance, an actual or likely serious adverse outcome, and the need for immediate corrective action. Its core guidance distinguishes an immediate-jeopardy removal plan from complete correction of the underlying deficiencies.
How should repeat findings change the order?
In IHS's reading, repeat findings deserve the next investigation priority after immediate safety because the previous corrective approach needs testing. Compare the current observation with the earlier finding, promised action, implementation record, and monitoring results.
Can we group several citations under one root cause?
Yes, in IHS's reading, when evidence supports a shared failure mechanism and each citation remains separately traceable. Triage only decides what to group provisionally; the investigation that confirms the cause is separate work.
Test whether the proposed correction would address every linked finding, including findings outside the department where the problem first appeared. If it would not, split the group.
Who should own each corrective action?
In IHS's reading, assign each action to someone with authority over the affected operation, and identify who will verify its completion. The compliance lead can coordinate the response without becoming the owner of every clinical or operational change. Name an internal due date that leaves time for approvals and evidence review before the external deadline. ACHC's hospital guidance asks for the responsible leader's or committee's title for corrective actions and for monitoring.
What evidence should we identify before drafting?
In IHS's reading, define both proof that the change occurred and a way to test whether it works before drafting the response. Link each citation to the relevant record, observation, or review result; identify who will collect it and what would trigger more corrective work.
ACHC's hospital guidance calls for monitoring dates and frequency, a compliance threshold, and a reporting recipient. CMS Appendix Q's core guidance calls for implementation and onsite surveyor verification for immediate-jeopardy removal, and written approval alone does not establish removal. Its laboratory section differs: if a laboratory stops testing, immediate jeopardy is treated as removed, and an onsite revisit is still required later to determine substantial compliance.
What this is NOT
This is triage before drafting a plan of correction. It does not address a plan that has already been rejected or the broader human work of post-incident recovery.
This is not legal advice. Ask counsel to assess disputed findings, legal exposure, and any challenge strategy.
This page does not establish your organization's deadline or resolve state-specific obligations. Its federal and accreditor examples retain the program limits stated above.
Frequently asked questions
Do we need a consultant to triage citations?
Often not for the triage itself. Your own compliance and clinical leaders can build the citation list, confirm the issuer's deadline and format, and assign owners. In IHS's reading, outside help adds most where a finding crosses departments or where the team has no one free to test the evidence; a consultant can map evidence to each finding and draft the plan for your leaders to approve. Counsel belongs on the matter if you intend to dispute a citation or the findings raise legal exposure.
What does IHS do before the client submits?
IHS maps findings, assesses gaps, and drafts materials for the client's responsible leaders and clinicians to review and approve. The client sends the response. IHS does not contact, submit to, confirm with, or represent a client before an accreditor, regulator, or payer.
About the author
Thomas G. Goddard, JD, PhD is Chief Executive Officer of Integral Healthcare Solutions, which he has led since 2002. He was Chief Operating Officer and General Counsel of URAC from 1998 to 2000.
Integral Healthcare Solutions: accreditation consulting, compliance services, and program development.
Sources
42 CFR 488.28, Providers or suppliers with deficiencies, subject to the exclusions in its title. CMS, published through eCFR. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-A/section-488.28
42 CFR 488.30, Revisit user fee for revisit surveys. CMS, published through eCFR. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488/subpart-A/section-488.30
State Operations Manual, Appendix Q, Core Guidelines for Determining Immediate Jeopardy, sections IV and VII. CMS. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf
Hospital correction-plan guidance, article dated March 14, 2024. Accreditation Commission for Health Care. https://achc.org/write-a-plan-of-correction/
State Operations Manual, Chapter 2, The Certification Process, section 2728B (Plan of Correction). CMS. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107c02.pdf
Evidence of Standards Compliance instructions. The Joint Commission. https://digitalassets.jointcommission.org/api/public/content/35e1651ba7394a63b4a4a9451f2d154d?v=cec658de
Specialty Pharmacy Accreditation Process, revised April 4, 2023. Accreditation Commission for Health Care. https://achcu.com/wp-content/uploads/2023/06/ACHCU-Specialty-Pharmacy-Process.pdf
Steps to accreditation, step 8. CARF International. https://carf.org/accreditation/steps-accreditation/
2021 Health Plan Policy Updates. National Committee for Quality Assurance. https://wpcdn.ncqa.org/www-prod/wp-content/uploads/2021/07/20210726_2021_HP_Policy_Updates.pdf
Last updated: October 30, 2026. Sources were retrieved on that date. Requirements change and must be verified with the issuing body.