POCDesk editorial team · Educational checklist · Updated September 16, 2026

Plan of Correction Submission Checklist

Organize a CMS-2567 response and verify the applicable date, instructions, and evidence with the State Survey Agency. This is not an official CMS form or approval.

Before writing

1. Log the date the facility received the CMS-2567 and confirm the submission instructions and due date with the State Survey Agency.
2. For every citation, copy the F-Tag, regulation, scope/severity, and specific survey evidence into a response worksheet.

Five-element response

3. Describe corrective action for affected resident(s), including what was done, by which role, and when.
4. Define how all other potentially affected residents were identified, screened, and protected; record the population and findings.
5. Document the system change: policy, workflow, equipment, competency process, handoff, or other root-cause response.
6. Write a monitoring plan with owner by role, measure, sample/population, frequency, duration, reporting destination, and escalation threshold.
7. Set a completion date the facility can support with records. Do not allege work that has not occurred.

Review and submission

8. Have the administrator, DON, and relevant department owners fact-check the response and retain proof of submission.
9. If disputing a finding, ask the State Survey Agency about IDR separately; do not assume a dispute changes the POC instructions or deadline.

Primary sources

• Official CMS-2567 form and instructions
• CMS Nursing Home Enforcement FAQ
• CMS State Operations Manual Chapter 7
• CMS State Survey Agency contacts

Coverage limitation: verify facility-specific instructions, deadlines, and findings with the State Survey Agency or CMS. This checklist does not replace the official CMS form or agency direction.