Summary of SA Certification Actions Performed After Survey

2726 - Summary of SA Certification Actions Performed After Survey (Rev. 1, 05-21-04) Following are summaries of eight SA steps of the post-survey certification process: 1. Prepare survey documents for eventual public disclosure. 2. Send Form CMS-2567 to the provider/supplier, requesting a PoC if appropriate. A PoC is required for all deficiencies except as noted in §2728.B. 3. If extensive documentation is required for adverse action, gather the necessary additional evidence. Only achievement of compliance stops termination action. A PoC may not be required when termination action is recommended because the PoC cannot substitute for Condition-level noncompliance. Review and evaluate the PoC to: • Ascertain whether compliance is likely to be achieved in a time acceptable to you or the RO, as appropriate; and • Help structure the revisit after a credible allegation of compliance is received. 4. Consider waivers of requirements (if explicitly allowed) that may be appropriate. Prepare recommendations accordingly or, in the case of Medicaid-only waivers, prepare determinations granting or denying waivers. 5. Certify compliance or noncompliance. 6. Assemble all required documentation for transmission to the RO or, in a Medicaid- only case, to the SMA. 7. If necessary, schedule a revisit to verify the provider’s follow-through on acceptable PoCs. Schedule future surveys for the next certification interval, taking into account the provider’s accreditation status if applicable, the anticipated duration of waivers, and, as required by OBRA ‘87, flexible survey cycles for SNFs, NFs, and HHAs. 8. Be prepared to modify the revisit schedule for unexpected changes or requested changes in providers’ coverage status or for subsequent changes in compliance status.