How systemic change is understood by nursing home leaders and implemented using plans of correction
(2026) FLMU16 20252Division of Risk Management and Societal Safety
- Abstract
- When there is a statement of deficiency given to a nursing home, the Centers for Medicare & Medicaid Services (CMS) requires facilities to submit a plan of correction stating how they will create systemic change to prevent recurrence of the incident. This study reviewed 90 statements of deficiency and associated plans of correction from across the United States for abuse, neglect, and exploitation from July 1, 2024 through December 31, 2024. Data analysis of the plans of correction showed that 100% included education and re-training as systemic changes. While these may be useful strategies, research in human factors and system safety defines education and re-training as quick fixes, not systemic changes. Interviews with nursing home... (More)
- When there is a statement of deficiency given to a nursing home, the Centers for Medicare & Medicaid Services (CMS) requires facilities to submit a plan of correction stating how they will create systemic change to prevent recurrence of the incident. This study reviewed 90 statements of deficiency and associated plans of correction from across the United States for abuse, neglect, and exploitation from July 1, 2024 through December 31, 2024. Data analysis of the plans of correction showed that 100% included education and re-training as systemic changes. While these may be useful strategies, research in human factors and system safety defines education and re-training as quick fixes, not systemic changes. Interviews with nursing home leadership were conducted to determine what understanding leaders had of systemic change and how they use plans of correction to implement systemic change in their facilities. These interviews revealed that leaders know quick fixes are not improving quality in facilities but feel the survey process and overall compliance and regulation is not designed to address underlying systemic issues. The study also found conflicting guidance available from CMS on its expectations of systemic change. (Less)
Please use this url to cite or link to this publication:
http://lup.lub.lu.se/student-papers/record/9225709
- author
- Gadd, Shannon LU
- supervisor
-
- James Nyce LU
- organization
- course
- FLMU16 20252
- year
- 2026
- type
- H1 - Master's Degree (One Year)
- subject
- keywords
- FLMU06
- language
- English
- id
- 9225709
- date added to LUP
- 2026-04-27 10:13:08
- date last changed
- 2026-04-27 10:13:08
@misc{9225709,
abstract = {{When there is a statement of deficiency given to a nursing home, the Centers for Medicare & Medicaid Services (CMS) requires facilities to submit a plan of correction stating how they will create systemic change to prevent recurrence of the incident. This study reviewed 90 statements of deficiency and associated plans of correction from across the United States for abuse, neglect, and exploitation from July 1, 2024 through December 31, 2024. Data analysis of the plans of correction showed that 100% included education and re-training as systemic changes. While these may be useful strategies, research in human factors and system safety defines education and re-training as quick fixes, not systemic changes. Interviews with nursing home leadership were conducted to determine what understanding leaders had of systemic change and how they use plans of correction to implement systemic change in their facilities. These interviews revealed that leaders know quick fixes are not improving quality in facilities but feel the survey process and overall compliance and regulation is not designed to address underlying systemic issues. The study also found conflicting guidance available from CMS on its expectations of systemic change.}},
author = {{Gadd, Shannon}},
language = {{eng}},
note = {{Student Paper}},
title = {{How systemic change is understood by nursing home leaders and implemented using plans of correction}},
year = {{2026}},
}