Approval and Correction of Deficiencies

1016 - Approval and Correction of Deficiencies (Rev. 1, 05-21-04) The Medicare CoPs, Requirements for SNFs and NFs, and CfCs are sets of requirements for acceptable quality in the operation of health care entities. There is a set of Conditions, or Requirements for SNFs and NFs, for each type of provider or supplier subject to SA certification. In addition to each Condition, or Requirement for SNFs and NFs, there is a group of related quality standards, with the Condition or Requirement expressed in a summary lead sentence or paragraph characterizing the quality or result of operations to which all the subsidiary standards are directed. The SA ascertains, by a survey conducted by qualified health professionals, whether and how each standard is met. While an institution may fail to comply with one or more of the subsidiary standards during any given survey, it cannot participate in Medicare unless it meets each and every Condition or attains substantial compliance with requirements for SNFs and NFs. NOTE: CMHCs have no conditions of participation or coverage to meet. CMHCs do have to meet certain core public health service requirements prior to Medicare approval. FQHCs do have conditions of coverage to meet, as found at 42 CFR 491. However, FQHCs attest to meeting the CfCs, rather than undergo a survey. Many Condition or Requirement summaries are identical to statements of the statute. The essence of what the SA certifies to CMS is a finding of whether an institution meets each of the CoPs or substantially meets each requirement for SNFs and NFs applicable to it, and whether each supplier of services meets each CfC applicable to it. The SA prepares its certification for the RO, sends the institution a "Statement of Deficiencies," Form CMS-2567. The institution is given 10 calendar days in which to respond with a Plan of Correction (PoC) for each cited deficiency, and enters this response on the form containing the statement of deficiencies. This form, with written deficiencies and acceptable PoC, is available for public inspection at the SA office and the nearest RO, and can be requested through the Freedom of Information Act (FOIA). If the institution has not come into compliance with all Conditions or Requirements for SNFs and NFs within the time period accepted as reasonable, the SA certifies noncompliance notwithstanding a PoC. The SA's finding constitutes a final determination (except in the case of a State-operated Medicaid-only NF or a NF subject to a validation survey or a review by CMS when CMS’ decision is binding), when a Medicaid-only facility is noncompliant. The SMA must undertake either an action to terminate the non-complying facility's Medicaid participation or, if a NF, apply one or more of the remedies specified in §1919(h) of the Act, or it may do both.