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Survey and compliance, handled.

Skilled nursingRegulatory complianceWeb platform
app.tactis.ai/plans-of-correction
Tactis Plan of Correction builder with cited tags and drafted sections
Plan of Correction
SourceSurvey 12-5-2024 CMS-2567.pdf
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)

Residents/rooms cited: R1

1. Corrective action for affected residents

On December 4, 2024, the DON observed R1 take her medications as ordered. The interdisciplinary team assessed R1 for safe self-administration the same day.

2. Identification of others with potential to be affected

All residents who self-administer medications were reviewed for a current IDT assessment, a physician's order, and a matching care plan.

3. Systemic changes to prevent recurrence

Licensed nurses were re-educated on the self-administration policy. An IDT assessment is now required before any self-administration order is written.

4. Monitoring to sustain the correction

The DON or designee will observe five medication passes weekly for four weeks, then monthly for two months.

5. QAPI inclusion and sustained compliance

Results are reported to the QAPI committee monthly until compliance holds at 100% for three consecutive months.

6. Completion date

January 9, 2025

The problem.

Skilled nursing runs on a regulation nobody can search, over data nobody may leak. One deficiency on a 2567 starts a ten-day clock for the Plan of Correction. General AI answers with confidence and without a source, and an answer you can't verify is a liability.

What I built.

Answers with the regulation attached.

Ask about an F-tag, a survey process, or a star rating. The answer arrives with its sources cited, and says so when the regulation doesn't support one.

app.tactis.ai/copilot
Tactis Regulatory Copilot answering with cited sources

From 2567 to Plan of Correction.

Upload the Statement of Deficiencies, or describe a problem you found yourself. Tactis reads the cited tags and drafts every section the federal format requires.

app.tactis.ai/plans-of-correction/new
Tactis Plan of Correction start screen

Proof that the fix happened.

Sign-in sheets are read automatically and matched to the required staff list, so you know who still needs the in-service before a surveyor asks.

app.tactis.ai/compliance-center/in-service
Tactis Compliance Center in-service attendance tracking

Built for resident data.

Every facility's data is encrypted under its own key. Every access lands on a tamper-evident record. Two-factor sign-in is required, and nothing a facility enters is ever used to train a model.

Facility encryption keyMaple Hollow Health & Rehab
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Two-factor sign-inRequired for every user
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Access recordChain verified this morning
Intact
Model training on your dataResident data stays yours
Never

The whole binder, drafted.

Every cited tag gets its paper trail: QAA meeting minutes, a baseline audit of other residents, an in-service packet with its sign-in sheet, a monitoring tool, and a QAPI committee packet. Ready to print and sign.

poc-binder-survey-12-5-2024.zip
  • F554 - Resident Self-Admin Meds/
    • 0 - Plan of Correction.docx
    • 1 - Meetings/
    • 2 - Others audit/
    • 3 - Mandatory In-Service Education Packet.docx
    • 4 - Monitoring/
    • 5 - QAA/QAPI Committee Packet.docx
  • F578 - Request/Refuse/Discontinue Treatment/
  • F656 - Comprehensive Care Plans/
QAA/QAPI Committee Packet
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)
Performance Improvement Project (PIP) Charter

Problem statement: Residents self-administered medications without an IDT assessment on file.

Goal/Aim: 100% of self-administering residents assessed, ordered, and care planned.

Scope: All units, all licensed nurses.

Root cause: No step required the assessment before the order was written.

Measure: Weekly medication pass observations.

QAA/QAPI Committee Agenda
  1. Review of monitoring results
  2. In-service attendance
  3. Determination
Committee chair: Date:
Administrator: Date:
QAA Sub-Committee Meeting Minutes
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)
Facility:
First QAA Sub-Committee Meeting
Date:December 5, 2024
Attendees:Administrator, DON, Infection Preventionist, Medical Director
Discussion
  • Reviewed the deficient practice cited under F554.
  • Confirmed immediate corrective action for R1.
  • Approved the audit of all self-administering residents.
  • Assigned re-education of licensed nurses to the DON.
Ongoing Meetings

The sub-committee meets weekly until the plan is complete.

Minutes recorded by: Date:
Committee chair: Date:
In-Service Education
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)
Audience
Instructor
Date/Time conducted
Learning objectives
  1. Explain when a resident may self-administer medications.
  2. Describe the IDT assessment required before an order.
  3. Observe and document safe self-administration.
Competency check
Skill / behavior demonstratedMeetsNeeds trainingInitials
Verifies the IDT assessment
Observes the resident take the dose
Attendance & attestation
Name (print)Title / roleDate/TimeSignature
Baseline Audit: Other Residents
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)
Date completed
Question key
3. Self-administration assessment completed by the IDT?   4. Physician's order for self-administration on file?   5. Care plan reflects self-administration?
1. Resident2. Date reviewed345Affected?Correction madeMonitored by
(enter resident name)YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
Reviewed by: Date:
Compliance Monitoring Tool
F554 · Resident Self-Admin Meds, Clinically Appropriate (Scope/Severity D)
Period:
Question key
4. Resident observed taking every dose?   5. IDT assessment current?   6. Order and care plan match?
1. Resident2. Date3. Staff observed456Monitored by
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
YES  NO  N/AYES  NO  N/AYES  NO  N/A
Observations this period:  Compliant:  Compliance %:
Administrator / DON review: Date:
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