Statement of Deficiencies and Plan of Correction, Form CMS-

2728 - Statement of Deficiencies and Plan of Correction, Form CMS- 2567 (Rev. 1, 05-21-04) Form CMS-2567 (see Exhibit 7) serves several of the following important functions: • It is the basic document disclosed to the public about the entity’s deficiencies and what is being done to remedy them; • It documents the specific deficiencies cited; • It documents any promises made by the provider/supplier, i.e., the provider/supplier’s plans for correction and timeframes; and • It provides an opportunity for the provider to refute survey findings and furnish documentation that requirements are met. The fire authority performing a LSC survey usually completes a separate Form CMS-2567. However, Form CMS-2567 for the LSC and health surveys may either be combined or processed separately. When there are no deficiencies (including LSC if applicable), the SA indicates that the entity is in compliance with all requirements. Refer to Principle #1 in Appendix 7A, for specific guidance on preparing this statement. The SA mails the provider/supplier a copy of Form CMS-2567 within 10 working days after the survey. If there are deficiencies, the SA allows the provider/supplier 10 calendar days to complete and return the PoC. Requirements pertaining to submittal of the PoC can be found in subsection B. 2728A - Statement of Deficiencies (Rev. 1, 05-21-04) The surveyor prepares Form CMS-2567 using the instructions provided in Appendix 7A. For each Requirement not met, the surveyor makes a citation that includes the following: • The prefix and data tag number; • The deficiency that contains the CFR or LSC reference, the Requirement that is not met, and an explicit statement that the Requirement is “not met”; and • The evidence to support the deficiency. If the ASPEN computer database program is used to generate Form CMS-2567s, the statement of deficiencies will automatically be generated in the general format required by, Appendix 7A and will simply require the surveyor to enter the evidence to support the deficiency. If ASPEN is not used, the surveyor lists all deficiencies in the left column of Form CMS-2567 preceded by the data prefix tag. The data prefix tag is printed to the left of the regulatory paragraph on each survey report. If a waiver is requested, the surveyor places an asterisk to the left of any deficiency for which the waiver is recommended. In instances where the facility is in substantial compliance but a deficiency exists and the only data tag on the survey form is for the Condition (e.g., ASCs), the surveyor lists the deficiencies, states that no Condition-level deficiency exists, and does not use a data prefix tag. NOTE: This practice is not allowed in cases where there are prefix data tags for Standards and/or elements below the Condition level. (Requirement for SNFs/NFs.) Surveyors must express deficiencies clearly and concisely with a regulatory citation for each. For examples of proper deficiency citations, refer to Exhibit 7A, “Principles of Documentation.” 2728B - PoC (Rev. 1, 05-21-04) Regulations in 42 CFR 488.28(a) allow certification of providers/suppliers (other than SNFs and NFs) with deficiencies at the Standard level “only if the facility has submitted an acceptable PoC for achieving compliance within a reasonable period of time acceptable to the Secretary.” Failure to submit a PoC could result in termination of the provider agreement as authorized by 42 CFR 488.28(a), 488.456(b)(1)(ii), and 489.53(a)(1). After a PoC is submitted, the surveying entity makes the determination of the appropriateness of the PoC. (See §7500 for SNFs/NFs.) This “reasonable period of time” (to achieve compliance) is generally no longer than 60 calendar days. Of course, the correction date for a specific deficiency may be less or greater than 60 calendar days after the survey depending on the circumstances of the deficiency. The SA should not accept dates for correction routinely for 60 calendar days when the deficiency can reasonably be corrected well before 60 calendar days. On the other hand, a provider may reasonably require more time than 60 calendar days to correct some deficiencies, i.e., those requiring construction, or other deficiencies where correction is clearly beyond the control of the provider/supplier. (See 42 CFR 488.28(b) for further guidance on correction dates.) The provider/supplier cited with deficiencies has the following three options: • Accept the deficiencies stated on Form CMS-2567 and submit a PoC; • Record objections to the cited deficiencies on Form CMS-2567 and submit a PoC; or • Record objections to cited deficiencies on Form CMS-2567, do not submit a PoC, and provide convincing arguments and documented evidence that the deficiencies are invalid. An acceptable plan of correction must contain the following elements: • The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; • The procedure for implementing the acceptable plan of correction for the specific deficiency cited; • The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; • The title of the person responsible for implementing the acceptable plan of correction. NOTE: The option to record objections pertains only to the opportunity to refute the accuracy of the findings incorporating the deficiency. Providers/suppliers may not refute the professional judgment of the surveyor regarding the level, extent, scope, or severity of the deficiency. The surveying agency will consider evidence arguing the existence of a deficiency, but will not consider documentation that argues the seriousness of the deficiency. If a provider attempts to refute the deficiencies, the SA reviews the documentation submitted by the provider. If the provider provides the SA with indisputable documented evidence that the deficiencies that are the basis for noncompliance are invalid, the SA revises Form CMS-2567 to reflect compliance with the CoPs/requirements, and certify the provider/supplier upon receipt of an acceptable PoC for any remaining deficiencies. In all three options, the provider or supplier response to the deficiency is entered on the right side of Form CMS-2567, opposite the deficiency. The PoC must include the provider/supplier’s planned action to correct the deficiency and the expected completion date. (See §7500 for further documentation for SNFs/NFs.) PoCs must be specific and realistic, stating exactly how the deficiency was or will be corrected. The PoC must be signed and dated by the administrator or other authorized official. Additional documentation may be attached to Form CMS-2567, if necessary. If a deficiency has been corrected since the survey, this should be indicated on the form along with the approximate date of correction. If the administrator requests additional time to develop the plan, the SA asks that it be completed as precisely as present information permits, and that it be followed with a more specific plan as early as possible. The SA advises the administrator to return the PoC to them promptly. Also, the SA informs the administrator that, except for SNFs and NFs, the law requires that Form CMS-2567 must be made available for disclosure to the public within 90 calendar days of the last day of the survey. (See 42 CFR 401.133.) For SNFs and NFs, §§1819(g)(5) and 1919(g)(5) of the Act require disclosure of Form CMS-2567 to the public within 14 calendar days after it is made available to the provider. In addition, the SA advises that a future contact will be made to determine that the corrections have been made as agreed. The provider/supplier should retain a copy of Form CMS-2567 and return the original copy to the SA within 10 calendar days of receipt. If a multi-copied Form CMS-2567 is used, the provider retains the fifth copy and returns all other copies to the SA. As indicated above, the provider/supplier may attempt to refute the deficiency(ies) on Form CMS-2567. If so, the SA tries to resolve the disagreement and document the resolution. If the provider/supplier has attempted to refute a deficiency or deficiencies without submitting a PoC, but has not provided the SA with documented evidence that successfully refutes the validity of the deficiency, the SA notifies the provider/supplier in writing that its arguments are rejected and the reasons for the rejection. The SA advises the provider/supplier that failure to submit an acceptable PoC may result in recommendations to terminate its participation. If the provider then refuses to submit an acceptable PoC, the SA recommends termination to the RO (or the SMA for title XIX only providers) via a Form CMS-1539. The SA includes in the termination packet all pertinent documentation and correspondence related to the survey in question. NOTE: In the event of noncompliance with the CoPs or requirements for SNFs and NFs, a “credible allegation of compliance” is required before a revisit is conducted. (See §3014.) It is not acceptable under any circumstances for a provider or supplier to allude in any way to another provider or to malign an individual on a publicly disclosable Form CMS-2567. When this occurs, such statements must be removed and an amended PoC obtained by the SA. 2728C - Review of PoCs by SA (Rev. 1, 05-21-04) The SA reviews the provider or supplier’s PoC for appropriateness, legibility, and completeness. If the PoC is not properly completed or if there is a question about it, the SA contacts the provider or supplier representative to obtain clarification or an appropriate modification of the plan. (See §2728.E.) If multi-copied Forms CMS-2567 are used, the SA retains the fourth copy of Form CMS-2567 in the SA file and associate the remaining copies with the certification packet. 2728D - Modifications of PoCs (Rev. 1, 05-21-04) The provider or supplier may submit evidence of correction or a modified PoC to the SA at any time. The SA retains a copy of the material in the certification file and forwards the original to the RO or SMA, as appropriate. If the modification does not change the certification, it is not necessary to report verification of the corrections until after the next scheduled resurvey or revisit. 2728E - Rejection of Unacceptable PoCs (Rev. 1, 05-21-04) If the SA finds that a PoC is not acceptable, it rejects it and seeks an acceptable one from the provider in writing. Generally, changes to the PoC must be made by the provider/supplier. The SA does not amend a PoC without the provider’s concurrence. Changes to a PoC must be signed by the provider/supplier. However, if the adjustments required to the PoC are minor in nature (e.g., the provider failed to include a date for one of several deficiencies), the SA may contact the provider by telephone, make the necessary adjustments on Form CMS-2567, and then submit the change to the provider. 2728F - Major Deficiencies Requiring Long-Term Correction in Hospitals, SNFs, NFs, SNF/NFs, and ICFs/IID (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Some LSC deficiencies will require longer-term PoCs. For example, the installation of a sprinkler system will usually take from 18 to 36 months. Since PoCs may not be accepted for a period to exceed 6 months for SNFs and NFs, and one year for hospitals and ICFs/IID, the following procedure should be followed: • A LSC waiver should be recommended for the length of time to correct the deficiency including time for design and construction; • A written schedule of milestones in the design and construction of the corrective action should be included in the waiver request to determine if the work is progressing in an acceptable manner during any subsequent revisits; e.g., has the State Fire Marshall approved the hydraulic plans for the sprinkler system; and • In the interim, the facility should be certified as “Meets LSC based on waivers” rather than “Meets based on a PoC.”