Mandatory Elements of IDR

10002.3 - Mandatory Elements of IDR (Rev. 221; Issued: 05-10-24; Effective: 05-10-24; Implemetation:05-10-24) Upon their receipt of the official Form CMS-2567, agencies must be offered one informal opportunity, if they request it in writing, to dispute condition level deficiencies. Deficiencies cited at the standard level are not subject to the IDR process. The following elements must be included in each IDR process offered: 1. Agencies may not use the IDR process to delay the formal imposition of sanctions or to challenge any other aspect of the survey process, including: • The severity assessment of a deficiency(s) at the standard level that constitutes substandard care or immediate jeopardy (IJ); • Sanctions imposed by the enforcing agency; • Alleged failure of the survey team to comply with a requirement of the survey process; • Alleged inconsistency of the survey team in citing deficiencies among agencies; and • Alleged inadequacy or inaccuracy of the IDR process. 2. HHAs or hospice programs must be notified of the availability of IDR in the letter transmitting the official Form CMS-2567. The letter should inform the facility of the following: • It may request the opportunity for IDR, and that if it requests the opportunity, the request must be submitted in writing; • The written request for IDR, from the facility, must include an explanation of the specific condition-level deficiencies that are being disputed; • The written request must be made within the same 10 calendar day period the facility has for submitting an acceptable plan of correction to the surveying entity; • The name and address, e-mail, and phone number of the person to contact at the CMS Location or the SA to request the IDR; • The IDR process that is followed in that State, e.g., telephone conference, written communication, or face-to-face meeting; and • The name and/or position title of the person who will be conducting the IDR, if known. NOTE: IDR is a process in which State agency officials make determinations of noncompliance. SAs should be aware that CMS holds them accountable for the legitimacy of the process including the accuracy and reliability of conclusions that are drawn with respect to survey findings. This means that while the SA may have the option to involve outside persons or entities they believe to be qualified to participate in this process, it is the SA, not outside individuals or entities that are responsible for IDR decisions. When an outside entity conducts IDR, the results of the IDR process may serve only as a recommendation of noncompliance or compliance to the SA. The SA will then make the IDR decision and notify the facility of that decision. CMS will look to the SA to assure the viability of these decision-making processes, and holds the SA accountable for them. Since CMS has ultimate oversight responsibility relative to a SA’s performance, it may be appropriate for CMS to examine specific IDR decisions or the overall IDR process to determine whether the decision is consistent with CMS policy. For dually participating or Medicare-only agencies, informal dispute findings are in the manner of recommendations to CMS and, if CMS has reason to disagree with those findings, it may reject the conclusions from IDR and make its own binding determinations of noncompliance. 3. Failure to complete IDR timely will not delay the effective date of any enforcement action against the facility. 4. When a facility is unsuccessful during the process at demonstrating that a deficiency should not have been cited, the SA must notify the facility in writing that it was unsuccessful. 5. When a facility is successful during the IDR process at demonstrating that a deficiency should not have been cited or should be revised: • The deficiency citation should be marked “deleted,” or “revised” as appropriate, and signed and dated by a supervisor of the surveying entity; and • Any enforcement action(s) imposed solely because of that deleted or revised deficiency citation should be rescinded. NOTE: The facility has the option to request a clean (new) copy of the Form CMS-2567. However, the clean copy will be the releasable copy only when a clean (new) plan of correction is both provided and signed by the facility. The original Form CMS-2567 is disclosable when a clean plan of correction is not submitted and signed by the facility. Deficiencies pending IDR should be entered into iQIES but will not be uploaded to the national database system until IDR has been completed. 6. An agency may request IDR for each survey that cites condition-level deficiencies. However, if IDR is requested for deficiencies cited at a subsequent survey, a facility may not challenge the survey findings of a previous survey for which the facility either received IDR or had an opportunity for it. Condition-level deficiencies that are not corrected and that are carried forward on a subsequent survey are not eligible for the IDR process. Condition-level deficiencies identified on a subsequent survey that are new are eligible to be reviewed through the IDR process. Additional information related to the effect of IDR on HHA alternative sanctions and hospice program enforcement remedies, including CMPs, is addressed in the appropriate sections of this chapter.