CMS · Survey deficiency reference

F925 · Plan of Correction Plan of Correction for an F925 Pest Control Citation

Parts of this page are awaiting primary-source text and are marked in the body. Nothing marked as pending has been paraphrased from secondary summaries.

What This Page Is

A plan of correction (POC) is the facility’s own document, written on the right side of the Form CMS-2567 opposite each cited deficiency, and reviewed by the State Survey Agency that issued the finding. This page sets out the structure CMS requires and how each requirement lands on a pest control finding under F925. It is not a form to fill in. A plan copied from a template and submitted unreviewed is the kind of plan this page describes as rejected.

The Regulation Being Corrected

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

and CMS’s definition of the program, from the F925 Guidance in Appendix PP Rev. 232:

An “effective pest control program” is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats).

Every element of the plan has to be read against those two sentences. The deficient practice is not “there were mice”; it is that the program did not eradicate and contain them, or did not exist as a program at all.

The Five Elements CMS Requires (Verbatim)

Appendix PP Rev. 232 restates the required elements of a plan of correction in its tag guidance, introducing them with: “the Plan of Correction (POC) is expected to include the required elements as identified at State Operations Manual, Chapter 7, §7317 – Acceptable Plan of Correction. These include:”

• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;

• Address how the facility will identify other residents having the potential to be affected by the same deficient practice;

• Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;

• Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and

• Include dates when corrective action will be completed.

(The passage appears, in identical form, in the guidance for F847 and F848. Chapter 7 §7317 itself was not in the verified source set for this page: [CONTENT PENDING — SOM CHAPTER 7 NOT IN THE VERIFIED SOURCE SET]. The five elements above are quoted from Appendix PP, which cites it.)

The Five Elements Applied to a Pest Finding

1. Corrective action for the residents found to have been affected. Which residents, which rooms, which areas, and what was done for each. For pests this means the treatment or removal of the activity the surveyor observed, the inspection and treatment of the affected residents’ rooms and belongings where the pest is bed bugs or lice, replacement or laundering of affected linens and furnishings, and the disposal of contaminated food or supplies in a kitchen finding. Name the residents by identifier as the survey report does, and give the date each action was completed. A plan that says only “pest control company treated the facility” has not addressed the residents.

2. Identification of other residents having the potential to be affected. How the facility found out whether the same condition exists elsewhere. For pests, the same condition is almost always elsewhere: a whole-facility inspection (every resident room, dining, kitchen and dry storage, laundry, soiled utility, loading dock, dumpster pad, mechanical rooms, staff areas), the method used (visual inspection, monitoring devices, canine inspection for bed bugs), who performed it and their credentials, the date, and what was found. Resident and staff interviews about sightings belong here, because that is the surveyor’s own probe. The finding of that sweep feeds element 1 for any new residents affected.

3. Systemic change so the deficient practice will not recur. This is the element that answers the regulation’s word “program.” What changed so that the facility now maintains an effective pest control program: a written program (in-house, contracted, or both) covering the whole facility; a sighting-report route from any staff member to the person responsible, with a required response time; action thresholds by pest and area; the containment work (door sweeps, screens, sealed penetrations, dumpster and dock sanitation, harborage removal) assigned as facilities work orders with dates; the kitchen’s receiving inspection and dry-storage controls; the bed bug and lice procedure that includes room inspection and adjacent-room containment, not only clinical treatment; and staff education on recognition and reporting. If the vendor contract changed, say how (scope, frequency, reporting), and attach nothing the reviewer cannot verify on revisit.

4. Monitoring to make sure solutions are sustained. Who monitors, how, how often, and where the results go. For pests: the position (not the person’s name) responsible for the program; the audit tool and its frequency (for example weekly rounds of high-risk areas for a stated number of weeks, then monthly); review of the vendor’s service reports and the sighting log at each visit; and reporting to the Quality Assessment and Assurance committee, with the frequency stated. Monitoring that stops on a date is not sustained; state the ongoing frequency after the intensive period ends.

5. Dates when corrective action will be completed. A completion date for each corrective action, and one overall date by which the facility asserts substantial compliance. The date has to be achievable and verifiable on a revisit; a plan with no dates, or with “ongoing” as the only date, is not complete.

The plan is signed and dated by the administrator or other appropriate individual and returned to the survey agency.

The Ten-Calendar-Day Clock

The plan of correction is due within ten calendar days of the facility’s receipt of the Form CMS-2567. For hospitals, Appendix A Rev. 238’s survey protocol states the deadline verbatim in its exit-conference instructions:

Inform the facility that a written plan of correction must be submitted to the survey agency within 10 calendar days following receipt of the written statement of deficiencies.

The long-term care statement of the same deadline sits in the State Operations Manual, Chapter 7, which was not in the verified source set for this page: [CONTENT PENDING — SOM CHAPTER 7 NOT IN THE VERIFIED SOURCE SET]. This reference’s methodology page records that the ten-day submission deadline is sub-regulatory (State Operations Manual, Exhibit 152) and that 42 CFR §488.28, sometimes cited for it, sets the compliance expectation instead. Confirm the deadline against the transmittal letter that accompanies the survey report; it controls.

What 42 CFR §488.28(a) does say, as quoted in Appendix A’s protocol, is why the plan matters: a provider with deficiencies may be certified “only if the facility has submitted an acceptable plan of Correction [POC] for achieving compliance within a reasonable period of time acceptable to the Secretary,” and “After a POC is submitted, the surveying entity makes the determination of the appropriateness of the POC.”

For a long-term care facility the clock is also an enforcement clock: the remedies that attach to a deficiency (and the timelines for a revisit and for a finding of substantial compliance) run from the survey, not from the plan, so a plan that is late or rejected consumes the correction period without stopping it. The specific remedy timelines are in Chapter 7 and are not stated here.

The Past-Noncompliance Exception

If the facility found and corrected the pest condition before the survey, the finding may be written as past noncompliance, and Appendix PP is explicit about what follows. The three criteria, verbatim:

1. The facility was not in compliance with the specific regulatory requirement(s) at the time the situation occurred;
2. The noncompliance occurred after the exit date of the last standard (recertification) survey and before the survey (standard, complaint, or revisit) currently being conducted, and
3. There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific F-tag or K-tag.

The surveyors must document the facility’s corrective actions in the CMS-2567; the facility is not required to submit a plan of correction.

For a pest finding this is the reason the program’s own records matter before any survey: a sighting log, the service report, the remediation, the follow-up inspection, and the date the area was confirmed clear are the “sufficient evidence” that turns a citation into past noncompliance with no plan required. The manual’s own immediate-jeopardy example under F600 turned on the opposite: “there was no record of the visit or proposal for remediation.”

What Distinguishes an Accepted Plan from a Rejected One

These distinctions are this reference’s reading of the five elements against pest findings and of publicly posted plans; they are not CMS text. The surveying entity decides acceptability, and a rejected plan is returned for revision, which spends the clock.

Rejected: the plan disputes the finding instead of correcting it. The right side of the 2567 is for the plan. A facility that disagrees with a finding pursues that separately (informal dispute resolution); a plan that argues “no pests were present” answers none of the five elements.

Rejected: the vendor is the plan. “Our pest control company treated the building on [date] and will continue monthly service.” Element 1 is not addressed for any resident, element 2 is absent, element 3 describes the arrangement that produced the citation, and element 4 names no one at the facility.

Rejected: the plan addresses the space and not the program. The kitchen was cleaned and treated; nothing changed about how a sighting anywhere else reaches anyone. The regulation requires a maintained program; the systemic-change element has to describe one.

Rejected: monitoring that cannot be verified. “The Director of Nursing will monitor for pests” with no tool, no frequency, no record, and no committee. On revisit the surveyor asks to see the audits; if there are none, the plan was not implemented.

Rejected: no dates, or dates that are only “ongoing.”

Accepted: each element is answered with something a revisit can verify. Named residents and rooms with completion dates (1); a documented whole-facility inspection with method, credentials, date, and results (2); a written program, a sighting-report route with a response time, thresholds, containment work orders with dates, a bed bug and lice procedure, staff education with sign-in sheets (3); a named position, an audit tool, a stated frequency during and after the intensive period, and reporting to the quality committee (4); a completion date for each action and an overall compliance date (5); signed and dated.

Accepted: the containment half is present. CMS’s definition is “eradicate and contain.” A plan whose only actions are treatments has answered half the definition. Exclusion repairs, sanitation at the dock and dumpster, kitchen receiving inspection, and harborage removal are the other half, and they are the facility’s work, not the vendor’s.

Accepted: the plan matches what the surveyor was told to look for. The surveyor’s procedure is to look for signs of vermin on tour and to ask staff, residents, and representatives whether they have observed pests. A plan that makes staff and residents’ observations part of the program (a reporting route, a log, a response time, and evidence residents were told how to report) closes the finding at the point where the surveyor will re-test it.

Confidence Notes

HIGH confidence for every quotation: the five plan-of-correction elements, the past-noncompliance criteria, and the F925 tag text are transcribed from Appendix PP Rev. 232 (Issued 07-23-25), and the ten-calendar-day statement and the §488.28(a) quotation from Appendix A Rev. 238 (Issued 03-20-26), both read in full from the reference’s archived copies of the CMS PDFs on September 11, 2026. The application of each element to a pest finding and the accepted-versus-rejected distinctions are the reference’s own analysis and are labeled as such. State Operations Manual Chapter 7 (§7317 and the long-term care statement of the submission deadline and enforcement timelines) was not in the verified source set and is cited, not quoted, with markers where its text would otherwise appear.