Definitions and Acronyms

10001 - Definitions and Acronyms (Rev. 221; Issued: 05-10-24; Effective: 05-10-24; Implemetation:05-10-24) Abbreviated standard survey means a focused survey other than a standard survey that gathers information on an HHA’s or hospice program’s compliance with fewer specific standards or CoPs. An abbreviated standard survey may be based on complaints received or other indicators of specific concern such as reapplication for Medicare billing privileges following a deactivation. (HHA: 42 CFR §488.705; Hospice: SOM Appendix M, Task I) An abbreviated standard survey is a focused survey that examines any standard(s) related to the reason for the survey. AO – National Accreditation Organization whose program is approved by CMS. (42 CFR §488.1) Certification of compliance means that the HHA or hospice program is in compliance with the CoPs and is eligible to participate in the Medicare program. (HHA: 42 CFR §488.740) CFR - Code of Federal Regulations. CMP - Civil money penalty. (HHA: 42 CFR 488.845; Hospice: 42 CFR §488.1245) CMS Location- previously known as CMS Regional Office(s), the CMS Location(s) are part of the Survey & Operations Group (SOG) within CMS. Complaint investigation, previously known as a complaint survey, means an onsite review that is conducted to investigate specific allegations of noncompliance. Condition-level deficiency means noncompliance as described in 42 CFR §488.24. A condition-level deficiency is any deficiency of such character that substantially limits the provider’s or supplier’s capacity to furnish adequate care or which adversely affects the health or safety of patients. Credible allegation of compliance is a statement or documentation that is realistic in terms of the possibility of the corrective action being accomplished between the exit conference and the date of the allegation; and that indicates resolution of the problems. Deficiency is a violation of the Act and regulations contained in part 484 for HHAs, subparts A through C of this chapter, and §418 for hospice programs, subparts C and D of this chapter, is determined as part of a survey, and can be either standard or condition-level. Directed plan of correction means CMS or the temporary manager (with CMS/SA approval) may direct the HHA or hospice program to take specific corrective action to achieve specific outcomes within specific timeframes. (HHA: 42 CFR §488.805; Hospice: 42 CFR §488.1250) Enforcement action means the process of imposing one or more of the following alternative sanctions for HHAs or enforcement remedies for hospice programs: termination of a provider agreement; suspension of payment for all new admissions; temporary manager; civil money penalty; directed plan of correction; or directed in-service training. (HHA: 42 CFR §488.810- 865; Hospice: 42 CFR §488.1200-1265) Extended survey (HHA only) means a survey that reviews additional CoPs not examined during a standard survey. It may be conducted at any time but must be conducted when substandard care is identified. (42 CFR §488.705) Immediate jeopardy means a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a patient(s). iQIES – Internet Quality Improvement and Evaluation System. New admission means an individual who becomes a patient or is readmitted to the HHA or hospice on or after the effective date of a suspension of payment sanction. (HHA: 42 CFR §488.805) Noncompliance means any deficiency found at the condition-level or standard-level. Partial extended survey (HHA only) means a survey conducted to determine if deficiencies and/or deficient practice(s) exist that were not fully examined during the standard survey. The surveyors may review any additional requirements which would assist in making a compliance finding. (42 CFR §488.705) Per day means a CMP imposed for the number of days a facility is not in substantial compliance with the CoPs. Per instance means a single event of noncompliance identified and corrected through a survey, for which the Act authorizes CMS to impose a sanction or remedy. (HHA: 42 CFR §488.805; Hospice: 42 CFR §488.1245(b)(6)) Plan of correction means a plan developed by the HHA or hospice program and approved by CMS that is the HHA’s or hospice program’s written response to survey findings detailing corrective actions to cited deficiencies and specifies the date by which those deficiencies will be corrected. Repeat deficiency means a condition-level citation that is cited on the current survey and is substantially the same as or similar to, a finding of a standard-level or condition-level deficiency cited on the most recent previous standard survey or on any intervening survey since the most recent standard survey. Repeated non-compliance is not on the basis that the exact regulation (that is, tag number) for the deficiency was repeated. (HHA: 42 CFR §488.805; Hospice: 42 CFR 488.1205) Standard-level deficiency means noncompliance with one or more of the standards that make up each condition of participation. Standard survey means a survey conducted in which the surveyor reviews the HHA’s or hospice program’s compliance with a select number of standards and/or CoPs to determine the quality of care and services furnished by an HHA or hospice program. (HHA: 42 CFR §488.705) State survey agency (SA) means the entity responsible for conducting most surveys to certify compliance with the Medicare participation requirements. Substandard care means noncompliance with one or more CoPs identified on a standard survey, including deficiencies which could result in actual or potential harm to patients. (HHA: 42 CFR §488.705) Substantial compliance means compliance with all condition-level requirements, as determined by CMS, the SA, or AO. (HHA: 42 CFR §488.705; Hospice: 42 CFR 488.1105) Temporary management means the temporary appointment by CMS or by a CMS authorized agent, of a substitute manager or administrator. The HHA’s or hospice program’s governing body must ensure that the temporary manager has authority to hire, terminate or reassign staff, obligate funds, alter procedures, and manage the HHA or hospice program to correct deficiencies identified in the HHA’s or hospice program’s operation. (HHA: 42 CFR §488.805; Hospice 42 CFR 488.1235) Validation survey means a survey of an accredited provider or supplier to validate the accrediting organization's CMS-approved accreditation process. These surveys are conducted on a representative sample basis, or in response to substantial allegations of non-compliance. (42 CFR 488.9(a))