SA Completion Instructions for Certification and Transmittal,

2764 - SA Completion Instructions for Certification and Transmittal, Form CMS-1539, 1-32 (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) The main purpose of Form CMS-1539 is to transmit the SA’s certification that a facility meets or does not meet the requirements for participation. The SA completes all applicable parts of the form for Medicare/Medicaid providers/suppliers. The SA completes items 1-32 as follows: Except for the signatures, the SA types (includes keyboard entry) all applicable entries on Form CMS-1539. NOTE: Within each item on Form CMS-1539 there are code numbers for data reduction purposes (e.g., (L1), (L2)). Item 1 - Medicare/Medicaid Provider No Leave this item blank on all initial certifications. CMS assigns the CCN for all new providers and suppliers. CCNs for hospitals and LTC facilities with multiple components and/or distinct parts are assigned by the RO using the following criteria: A - Long-Term Care Facilities (SNF or NF) with Distinct Parts One CCN is assigned and only one Form CMS-1539 prepared for the following situations (see §2779): • SNF/NF with a SNF or NF distinct part; and • SNF with a NF distinct part. B - Distinct Part SNF/NF of Hospitals or CAHs Two CCNs are assigned, one for the hospital/CAH and one for the SNF/NF. Prepare separate Forms CMS-1539 for certification actions regarding each provider. CCN are assigned in the following fashion: 1 - Hospital or CAH with Distinct-Part SNF Two CCNs are assigned, one for the hospital/CAH and one for the SNF. Prepare separate Forms CMS-1539 for certification actions regarding each provider. 2 - Hospital or CAH with Distinct-Part NF Two CCNs are assigned, one for the hospital/CAH and one for the NF. Prepare separate Forms CMS-1539 for certification actions regarding each provider. 3 - Hospital or CAH with Distinct-Part SNF/NF C -Hospitals or CAHs with Swing-Bed Approval One CCN is assigned, however the single CCN for the hospital or CAH is modified to address the hospital’s or CAH’s swing-bed approval. A letter `U’ or `Z’ in the third space of the CCN is used to identify swing-bed approval designation for a short-term hospital or CAH (See SOM section 2779C). Prepare one Form CMS-1539. EXAMPLE: 21-0101 – Is ABC Hospital’s (Short-Term Hospital) CCN • 21U101 – Is ABC Hospital’s modified CCN for its swing-bed approval EXAMPLE: 21-1301 –Is XYZ CAH’s CCN • 21-Z301 is XYZ CAH’s modified CCN for its swing-bed approval D –Hospital or CAH IPPS Excluded Rehabilitation or Psychiatric Units Hospitals or CAHs with psychiatric and/or rehabilitation units that are excluded from the IPPS are assigned one CCN but will have their CCN modified by adding an alpha identifier in the third space to identify their IPPS excluded rehabilitation unit and/or psychiatric unit. IPPS excluded units in CAHs are called “distinct part units (DPU)”. (See SOM section 2779C and 2779C1) Prepare one Form CMS-1539. Item 2 - State Vendor or Medicaid Number The SA completes this item only for those States that assign separate vendor (or Medicaid ID) numbers for internal controls or for billing purposes. The SA should leave this item blank if a State does not have such a system. Item 3 - Name and Address of Facility The facility properties screen of the national data system automatically generates the name, physical address, city, State, and zip code of the facility. A post office box without a street address is not sufficient. Item 4 - Type of Action In the block provided, the SA enters the appropriate code in accordance with the following explanations: Code 1 (Initial Survey) In addition to initial certifications, the SA selects this code when recommending an initial denial of participation. The SA indicates in Item 15 that it is recommending denial. Code 2 (Recertification) The SA selects this code when conducting a recertification survey. Code 3 (Termination or retirement of CCN) The SA selects this code for involuntary termination, voluntary termination/withdrawal, or change in status requiring a new CCN. Examples of a change in status includes: • When a hospital converts to a CAH, • When a CAH converts to a hospital, • When a short-term hospital reclassifies to become an IPPS-excluded hospital, • When an IPPS-excluded hospital reclassifies to become another classification of hospital (Short-term hospital or IPPS-excluded hospital), or • When a hospital undergoes a CHOW and then is combined with another hospital the new owner already owns. Code 4 (CHOW) The SA selects this code for a CHOW situation. Code 5 (Sample Validation) The SA selects this code for a complete survey in an accredited facility for sample validation purposes. The SA completes all appropriate blocks on the form including items 6 (survey date), 8 (accreditation status), and 10 (compliance provision). Code 6 (Complaints) The SA selects this code for an onsite complaint investigation. Code 7 (Onsite Visit) The SA selects this code for an onsite inspection of a facility for some other reason not outlined above. Examples include: 1. Onsite revisit to verify that the deficiencies cited on the original survey are corrected and a Form CMS-2567B is completed; 2. Onsite visit to verify that a hospital or CAH meets the criteria for hospitals or CAHs operating with swing-beds or IPPS-excluded units; and 3. Onsite visit to verify that an HHA’s satellite meets the branch criteria. Code 8 (Full Survey After Complaint) The SA selects this code for when a full survey after a complaint investigation is completed in the complaint system. Code 9 (Other) The SA selects this code for any certification action not specified above (e.g., changes in effective date, size, facility name, or address). Whenever action code 9 is selected, the SA shows in Remarks, Item 16, and the reason for completing Form CMS-1539. Item 5 - CHOW Date When Item 4 is marked CHOW (code 4), the SA is unable to enter the date the change occurred (e.g., 060782) in Item 5. CMS will enter the date the change occurred. Item 6 - Survey Date For providers who require a life safety code (LSC) survey, the SA enters the date the health or LSC survey is completed, whichever is later. For providers and suppliers who do not need a LSC survey, the SA enters the date the health survey is completed (e.g., 060283). Item 7 - Provider/Supplier Category In the block provided, the code that is most descriptive of the facility identified on the form is taken. The SA does not manually enter a code. Item 8 - Accreditation Status The SA does not manually enter accreditation status on this form. It is taken from the information already entered into the deemed tab of the certification kit and populated on the form. Item 9 (L35) - Fiscal Year Ending Date The MAC or CMS PEOG, when applicable, enters the ending date (month and day) of the provider’s/supplier’s fiscal year (e.g., 0630). Item 10 - State Agency Certification A - In Compliance With Program Requirements If “A” is entered in the first block and the facility is not in full compliance with the program requirements, all conditional aspects are coded in the blocks following “A.” For example, the SA enters A126 when a hospital is in compliance with the program requirements based on an acceptable PoC, recommended waivers for technical personnel, and limited scope of service. NOTE: A1 applies to all provider/suppliers with an acceptable PoC. A2 and A6 apply to hospitals only. A3 applies to hospitals, SNFs, and NFs only. A4 is no longer applicable. A8 and A9 apply to all LTC facilities. A5 applies to all facilities that undergo a fire safety survey. A7 no longer applies to SNFs. B - Not in Compliance With Program Requirements (Termination Development) If “B” is entered in the first block, the documentation supporting the termination action must accompany Form CMS-1539 and be referenced in Item 16 of Remarks. Item “B” is also selected when an accredited hospital is not in compliance with one or more of the CoPs surveyed during the sample validation survey or complaint investigation. C - Not in Compliance With Program Requirements (Denial of Payments for New Admissions for SNF, NF, and ICF/IID) 1 - Denial of Payments Recommended The SA marks “B” in the first block when a recertified SNF, NF, or ICF/IID is not in compliance with the program requirements and is a likely candidate for denial of payments for new admissions. The SA annotates Item 16, “Remarks” to indicate that a denial of payments may be applied. 2 - Resurvey Finds Substantial Compliance Following a revisit, the SA marks “A” in the first block when the facility is found to be in substantial compliance with the program requirements. The SA annotates Item 16, “Remarks” to show that the denial of payments for new admissions should be ended. D - Resurvey Does Not Find Significant Progress Following the revisit, the SA marks “B” in the first block when a facility is still not in compliance with program requirements and significant progress in correcting the deficiencies cannot be documented. The SA annotates Item 16 “Remarks” to show that the denial of payments for new admissions should remain in effect or that a termination action is being initiated. NOTE: In all cases, the appropriate SA documentation must accompany Form CMS-1539. Item 11 - LTC Period of Certification TLAs are no longer required for ICFs/IID. The SA does not need to insert the recommended beginning (FROM) and ending (TO) dates of the TLA. Item 12 - Total Facility Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) The SA enters the total number of beds in the facility, including those in non-participating and non-licensed components or areas. The Number of Beds in the Certified Portion of the Facility Must Not Exceed the Number of Total Beds. NOTE: The number of total facility beds and beds in the certified portion of the facility on Form CMS-1539 is restricted to the entire facility or the distinct part identified in Items 1 (CCN) and 7 (Provider Category). Item 13 - Total Certified Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) The SA enters the number of beds in Medicare and/or Medicaid certified areas. Item 14 - SNF, NF, and ICF/IID Certified Bed Breakdown The total number of beds in the certified portion of the facility recorded in Item 13 must be divided in Item 14 according to type of program (i.e., Box A-18 SNF, Box B-18/19, Box C-19 NF, and Box E-ICF/IID). Boxes D and F are no longer applicable. The SA completes boxes A, B, C, and E, as appropriate. These blocks must equal Item 13 (total beds in the certified portion of the facility). The examples on the following pages illustrate how Items 1 (CMS Certification Number) and 7 (Provider category) must be completed in conjunction with Items 12-14 for all hospital, SNF, NF, and ICF/IID providers. Item 15 - Nonparticipating Emergency Hospitals and NFs The SA enters code 1 or 2 in the block provided. The SA completes this block when a nonparticipating hospital meets the definition of an emergency hospital (see 42 CFR 424, Subpart G) in order to claim payment for emergency services rendered to Medicare patients. For participating NFs, the SA enters the appropriate code when the facility meets, or does not meet, the §1861(j) of the Act definition for durable medical equipment (DME) and home health benefit purposes. Item 16 - State Survey Agency Remarks The SA uses this space for any required remarks or recommendations for approval or disapproval. The SA should list the names of the surveyor and the SA approval in this space. If the comments exceed the allotted space, the SA continues on a sheet of paper entitled “Item 16 Continuation for CMS-1539.” The SA includes the provider number, if known, on the sheet for identification purposes. Whenever Item 4 is completed as “Other,” the SA uses “Remarks” to indicate the reason for completing Form CMS-1539. The following is a list of remarks which must be entered whenever appropriate. Remarks SOM Reference Exclusion from Certification (Non-PPS) §§2026, 2048, 2134, and 7016 Loss of Deemed Status Accreditation §2005B Certification of Additional Services §§3220, 3222 RHC Furnishes Home Health Services Determine Whether in HHA Shortage Area §2246 Waiver(s) Recommended §§2030, 2140, 2248, 2480, 7014 Multiple Locations §§2024, 2182, 2184, 2302, 2344 Denial of Payments Is Recommended §§3006, 7506 EXAMPLE 1 1. CCN | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0 | 1 | (Hospital) 3 0 0 3 0 0 14. LTC Certified Bed Breakdown | SNF | SNF | /NF | NF | ICF/IID | EXAMPLE 2: A total of 250 beds are in the combined hospital and DP SNF/NF Beds are distributed as follows: 200 beds in hospital portion 50 beds Title 18/19 DP SNF/NF NOTE: Prepare two Forms CMS-1539 identifying the separate hospital and SNF/NF providers. 1. CCN | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0|1 |(Hospital) 2 0 0 2 0 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 1. CCN | X | X | 5 | 0 | 0 | 0 | (SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0|2|(SNF/NF) 5 0 5 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 50 EXAMPLE 3: A Total of 400 beds are in the hospital and the DP NF Beds are distributed as follows: 300 hospital beds 100 beds Title 19 DP NF NOTE: Prepare two Forms CMS-1539 for hospital and LTC components. 1. CCN | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |0 |1 |(Hospital) 3 0 0 3 0 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 1. CCN | X | X |A,E, or F | 0 | 0 | 0 | (Title 19 NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |1 |0 | (NF 1 0 0 1 0 0 Distinct Part) 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 EXAMPLE 4: 44 bed hospital with swing-bed approval 1. CCN | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0| 1| (Hospital) 4 4 4 4 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | EXAMPLE 5: 100 bed nursing home (free-standing) Beds are distributed as follows: 60 beds certified for Medicaid 40 beds not participating in either Medicare or Medicaid 1. CCN (NF6: 75 Medicaid NF CCN| X | X |A, E, or F| 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 0 |(| (NF) 7 5 7 51 0 0 6 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 60 EXAMPLE 6: 75 bed Medicaid NF (free-standing) 1. CCN | SNF | SNF/NF | NF | ICF/IID | 75 EXAMPLE 7: 150 bed SNF/NF and NF Beds are distributed as follows: 100 beds SNF/NF 50 NF beds 1. CCN | X | X | 5 | 0 | 0 | 0 | (Title 18 & 19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |0 |3 |(SNF/NF) 1 5 0 1 5 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 50 EXAMPLE 8: 100 SNF/NF facility 100 beds - SNF/NF dually participating NOTE: Blocks A-E within item 14 must not exceed the total number of certified beds recorded in item 13. Report dually-participating beds in block B (18/19 SNF). Block F is no longer applicable. 1. CCN | X| X | 5 | 0 | 0 | 0 | (18/19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0| 2| (SNF/NF 1 0 0 1 0 0 Dually- Participating) 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 EXAMPLE #9: 125 bed SNF/NF facility Beds are distributed as follows: 100 beds - Title 19 NF 25 beds - Title 18/19 SNF/NF DP See Example #8 Note. 1. CCN | X | X | 5 | 0 | 0 | 0 | (18/19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0 | 3|(SNF/NF) 1 2 5 1 2 5 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 25 100 EXAMPLE 10: 150 bed Medicaid-only NF Beds are distributed as follows: 125 beds - Title 19 NF 25 beds - not participating in Medicare or Medicaid 1. CCN | X | X |A, E, or F | 0 | 0 | 0 | (Title 19 NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1 | 0| (NF) 1 5 0 1 2 5 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 125 EXAMPLE 11: 140 bed NF (free-standing) 1. CCN | X | X |A, E or F | 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 0| (NF) 1 4 0 1 4 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 140 | EXAMPLE #12 - 30 bed ICF/IID (free-standing) 1. CCN | X | X | G | 0 | 0 | 0 | (ICF/IID) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 1| (IMR) 3 0 3 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 30 | EXAMPLE #13 - 50 bed NF and ICF/IID facility Beds are distributed as follows: 30 beds - Title 19 NF 20 beds - Title 19 ICF/IID NOTE: Prepare two Forms CMS-1539 identifying the NF and ICF/IID components. 1. CCN | X | X |A, E, or F | 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1|0 | (NF) 3 0 3 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 30 1. CCN | X | X | G | 0 | 0 | 0 | (ICF/IID) 2 0 2 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 20 Item 17 - Surveyor Signature The surveyor (or survey team leader) signs and dates Form CMS-1539 after ensuring that the certification documents are complete and accurate. Item 18 - State Agency Approval The authorized representative of the SA signs and dates Form CMS-1539 and forwards the certification material to the MAC, when applicable or State Medicaid Agency (SMA), as appropriate. His/her signature constitutes for Medicare the official “certification” that the information being reported is correct according to official State files. In Medicaid-only cases, the SA representative’s signature on this document represents the adjudicative decision of the SA on the qualifications of the institution to participate in the Medicaid program. Item 19 - Determination of Eligibility Enter code 1 or 2 in this block of the SA’s findings and certifications. Enter code 1 when the provider/supplier is found eligible to participate in the Medicare and/or Medicaid programs. Also enter code 1 when a denial of payment for new admissions is imposed, continued, or lifted. Enter code 2 when a facility is not eligible to participate. Item 20 - Compliance with Civil Rights Act (Title VI) For providers/suppliers needing Office for Civil Rights (OCR) clearance, enter code 1 in the available block if the OCR requirements are met. If not in compliance with Title VI of the Civil Rights Act of 1964, as implemented by 45 CFR part 80, enter code 2 in the box that indicates that the provider is not eligible to participate. For Medicare Part B suppliers not requiring OCR clearance to participate, enter code 3 that indicates “not applicable.” Item 22 - Original Date of Participation Complete for initial certifications only. Determine when the facility is eligible to begin participation in Medicare and/or Medicaid. Enter the recommended effective date at block L24. The effective date of participation is established pursuant to 42 CFR 489.13 for Medicare and 42 CFR 431.108 for Medicaid. Items 23-25 - ICF/IID Certification Period (“LTC Agreements”) When an ICF/IID is found not to be in compliance with program requirements and a denial of payment for new admissions is imposed, enter the beginning (Item 23) and ending (Item 24) dates of the current re-certification survey. In Item 25 (extension date), enter a date not exceeding the end of the fifteenth month following the month in which the sanction will be imposed. Item 26 - Termination Action If a provider’s or supplier’s participation in the Medicare/Medicaid program ends, record the reason (see below) in the accompanying block. Also complete Item 28 (termination date). 1 - Voluntary Code 1 - Enter when a facility closes or merges. Code 2 - Enter when a provider or supplier is voluntarily withdrawing because of dissatisfaction with reimbursement. Code 3 - Enter when a facility is leaving the program because it is at risk of being involuntarily terminated. Code 4 - Enter when a provider or supplier no longer wishes to participate in the program for some other or unknown reason. 2 - Involuntary Code 5 - Enter when a facility fails to meet health or safety requirements (Conditions of Participation, Conditions for Coverage, Conditions for Certification, or Nursing Home Requirements). Code 6 - Select this code when a provider fails to meet the terms of their agreement. NOTE: If code 5 or 6 is selected, then the National Practitioner Data Bank (NPDB) appeal status box is generated in the national data system. The options to select are: 1 – No appeal, termination final 2 – Appeal in progress 3 – All appeals exhausted, termination final 3 - Other Code 7 - Select this code when you terminate a currently assigned CCN. Examples include: • Medicare SNF or dually-participating SNF/NF elects to participate in the Medicaid program only; • Medicaid NF elects to participate in the Medicare or Medicare and Medicaid programs; and • An ASC, ESRD, or RHC elects to participate as free-standing instead of hospital- based and vice versa. In any of the above instances, CMS terminates the existing CCN (complete Items 26 and 28) and assigns the new CCN. (See §1060.A.) Item 27 - Intermediate Sanctions (ICF/IID Only) When an ICF/IID is found not to meet the requirements of §1905(d) of the Act and the decision is made to impose an intermediate sanction rather than terminate participation, complete the pertinent items on Form CMS-1539 as follows: 1 - Suspension of Admissions Enter the date in Item 27A that payments for new admissions in the ICF/IID will be denied. In addition, mark Item 10 with “B” (not in compliance with program requirements). Mark Item 19 “1” (facility is eligible to participate). In Item 25 (extension date), enter a date not exceeding the end of the eleventh month following the month in which the denial of payments will be imposed. This date may not be extended. 2 - Rescind Suspension Date a - Significant Compliance with Program Requirements Enter the date the denial of payment is rescinded. The SA will mark Item 10 “A” (in compliance with program requirements) and Item 19 “1” (eligible to participate). In Item 27B, the RO enters the date the denial of payment is rescinded. NOTE: Items 23 and 24 can only be completed when Item 10 is marked ‘A’ (in compliance with program requirements). b -Significant Effort or Progress Item 27b may also be completed when Item 10 is marked “B” (facility is not in compliance with program requirements) and Item 16 (SA Remarks) is documented to show that effort and progress has been made to correct the deficiencies. Item 25 (ICF/IID extension date) remains unchanged. Mark Item 19 with “1” (facility is eligible to participate). NOTE: Pursuant to 42 CFR 442.119(a), the denial of payment for new admissions is to be rescinded if the facility has corrected deficiencies or can document it is making good faith efforts to achieve compliance with the conditions of participation. Good faith efforts would not, however, constitute compliance with program requirements. Therefore, it is conceivable that: • The denial of payments could be rescinded; • Effort and progress would be documented; • The SA would certify “not in compliance”; and • The extension would remain in effect. If the noncompliance deficiencies are not corrected by the 11th month following the initial month of denial, the ICF/IID’s provider agreement must be terminated pursuant to 42 CFR 442.119. NOTE: Similar information for SNFs/NFs is extracted from the Form CMS-462L, Adverse Action Extract for SNFs and NFs. Item 28 - Termination Date Enter the effective date of the termination action specified in Item 26. Item 29 – MAC Number Enter the five-digit number assigned to the MAC servicing the provider or supplier of health services. Item 30 – Remarks Use this block for any remarks that cannot be covered in the structured items above. If comments exceed space allotted in this item, document the additional comments on a sheet of paper entitled: “Item 30, Continuation for Form CMS-1539.” Item 31 – RO or MAC Receipt of Form CMS-1539 Enter the date that a certification package is received. For Medicaid-only providers, the SMA forwards the certification materials to the RO following review and completion. For Medicare, the SA forwards the package directly to the RO or MAC. Item 32 - Determination Approval Following review of the certification documents an authorized CMS or SMA representative must sign and date Form CMS-1539. 2764A - In Compliance With Program Requirements (Rev. 1, 05-21-04) If “A” is entered in the first block and the facility is not in full compliance with the program requirements, all conditional aspects are coded in the blocks following “A.” For example, the SA enters A126 when a hospital is in compliance with the program requirements based on an acceptable PoC, recommended waivers for technical personnel, and limited scope of service. NOTE: A1 applies to all provider/suppliers with an acceptable PoC. A2 and A6 apply to hospitals only. A3 applies to hospitals, SNFs, and NFs only. A4 is no longer applicable. A8 and A9 apply to all LTC facilities. A5 applies to all facilities that undergo a fire safety survey. A7 no longer applies to SNFs. 2764B - Not in Compliance With Program Requirements (Termination Development) (Rev. 1, 05-21-04) If “B” is entered in the first block, the documentation supporting the termination action must accompany Form CMS-1539 and be referenced in Item 16 of Remarks. Item “B” is also selected when an accredited hospital is not in compliance with one or more of the CoPs surveyed during the sample validation survey or complaint investigation. 2764C - Not in Compliance With Program Requirements (Denial of Payments for New Admissions for SNF, NF, and ICF/IID) (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 1 - Denial of Payments Recommended The SA marks “B” in the first block when a recertified SNF, NF, or ICF/IID is not in compliance with the program requirements and is a likely candidate for denial of payments for new admissions. The SA annotates Item 16, “Remarks” to indicate that a denial of payments may be applied. 2 - Resurvey Finds Substantial Compliance Following a revisit, the SA marks “A” in the first block when the facility is found to be in substantial compliance with the program requirements. The SA annotates Item 16, “Remarks” to show that the denial of payments for new admissions should be ended. 2764D - Resurvey Does Not Find Significant Progress (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Following the revisit, the SA marks “B” in the first block when a facility is still not in compliance with program requirements and significant progress in correcting the deficiencies cannot be documented. The SA annotates Item 16 “Remarks” to show that the denial of payments for new admissions should remain in effect or that a termination action is being initiated. NOTE: In all cases, the appropriate SA documentation must accompany Form CMS-1539. Item 11 - LTC Period of Certification TLAs are required for ICFs/IID. The SA inserts the recommended beginning (FROM) and ending (TO) dates of the TLA. If ICFs/IID are not in compliance with the CoPs, the SA establishes a conditional period of certification subject to automatic cancellation. When this occurs, the SA includes the cancellation date in Item 16, “Remarks.” Item 12 - Total Facility Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) The SA enters the total number of beds in the facility including those in non-participating and non-licensed components or areas. The Number of Beds in the Certified Portion of the Facility Must Not Exceed the Number of Total Beds. NOTE: The number of total facility beds and beds in the certified portion of the facility on Form CMS-1539 is restricted to the entire facility or the distinct part identified in Items 1 (Provider Number) and 7 (Provider Category). Item 13 - Total Certified Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) The SA enters the number of beds in Medicare and/or Medicaid certified areas. Item 14 - SNF, NF, and ICF/IID Certified Bed Breakdown The total number of beds in the certified portion of the facility recorded in Item 13 must be divided in Item 14 according to type of program (i.e., Box A-18 SNF, Box B-18/19, Box C-19 NF, and Box E-ICF/IID). Boxes D and F are no longer applicable. The SA completes boxes A, B, C, and E, as appropriate. These blocks must equal Item 13 (total beds in the certified portion of the facility). The examples on the following pages illustrate how Items 1 (Provider number) and 7 (Provider category) must be completed in conjunction with Items 12-14 for all hospital, SNF, NF, and ICF/IID providers. Item 15 - Nonparticipating Emergency Hospitals and NFs The SA enters code 1 or 2 in the block provided. The SA completes this block when a nonparticipating hospital meets the definition of an emergency hospital in order to claim payment for emergency services rendered to Medicare patients. For participating NFs, the SA enters the appropriate code when the facility meets, or does not meet, the §1861(j) of the Act definition for durable medical equipment (DME) and home health benefit purposes. Item 16 - State Survey Agency Remarks The SA uses this space for any required remarks. If the comments exceed the allotted space, the SA continues on a sheet of paper entitled “Item 16 Continuation for CMS-1539.” The SA includes the provider number, if known, on the sheet for identification purposes. Whenever Item 4 is completed as “Other,” the SA uses “Remarks” to indicate the reason for completing Form CMS-1539. The following is a list of remarks which must be entered whenever appropriate. Remarks SOM Reference Exclusion from Certification (Non-PPS) §§2026, 2048, 2134, and 7016 Loss of Accreditation - Will be Surveyed on _________ §2022.C Certification of Additional Services §§3220, 3222 Remarks SOM Reference RHC Furnishes Home Health Services Determine Whether in HHA Shortage Area §2246 Waiver(s) Recommended §§2030, 2140, 2248, 2480, 7014 Multiple Locations §§2024, 2182, 2184, 2302, 2344 Denial of Payments Is Recommended §§3006, 7506 EXAMPLE 1 1. Provider Number | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0 | 1 | (Hospital) 3 0 0 3 0 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | EXAMPLE 2: 250 bed hospital Beds are distributed as follows: 200 beds in hospital portion 50 beds Title 18/19 DP SNF/NF NOTE: Prepare two Forms CMS-1539 identifying the hospital and SNF/NF components. 1. Provider Number | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0|1 |(Hospital) 2 0 0 2 0 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 1. Provider Number | X | X | 5 | 0 | 0 | 0 | (SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0|2|(SNF/NF) 5 0 5 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 50 EXAMPLE 3: 400 bed hospital Beds are distributed as follows: 300 hospital beds 100 beds Title 19 DP NF NOTE: Prepare two Forms CMS-1539 for hospital and LTC components. 1. Provider Number | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |0 |1 |(Hospital) 3 0 0 3 0 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 1. Provider Number | X | X |A,E, or F | 0 | 0 | 0 | (Title 19 NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |1 |0 | (NF 1 0 0 1 0 0 Distinct Part) 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 EXAMPLE 4: 44 bed hospital swing-bed facility 1. Provider Number | X | X | 0 | 0 | 0 | 0 | (Hospital) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0| 1| (Hospital) 4 4 4 4 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | EXAMPLE 5: 100 bed nursing home (free-standing) Beds are distributed as follows: 60 beds certified for Medicaid 40 beds not participating in either Medicare or Medicaid 1. Provider Number | X | X |A,E, or F| 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 0 | (NF) 1 0 0 6 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 60 EXAMPLE 6: 75 bed Medicaid NF (free-standing) 1. Provider Number | X | X |A, E or F| 0 | 0 | 0 | (Title 19 NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |1 |0 |(NF) 7 5 7 5 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 75 EXAMPLE 7: 150 bed SNF/NF and NF Beds are distributed as follows: 100 beds SNF/NF 50 NF beds 1. Provider Number | X | X | 5 | 0 | 0 | 0 | (Title 18 & 19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS |0 |3 |(SNF/NF) 1 5 0 1 5 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 50 EXAMPLE 8: 100 SNF/NF facility 100 beds - SNF/NF dually participating NOTE: Blocks A-E within item 14 must not exceed the total number of certified beds recorded in item 13. Report dually-participating beds in block B (18/19 SNF). Block F is no longer applicable. 1. Provider Number | X| X | 5 | 0 | 0 | 0 | (18/19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0| 2| (SNF/NF 1 0 0 1 0 0 Dually- Participating) 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 100 EXAMPLE #9: 125 bed SNF/NF facility Beds are distributed as follows: 100 beds - Title 19 NF 25 beds - Title 18/19 SNF/NF DP See Example #8 Note. 1. Provider Number | X | X | 5 | 0 | 0 | 0 | (18/19 SNF/NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 0 | 3|(SNF/NF) 1 2 5 1 2 5 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 25 100 EXAMPLE 10: 150 bed Medicaid-only NF Beds are distributed as follows: 125 beds - Title 19 NF 25 beds - not participating in Medicare or Medicaid 1. Provider Number | X | X |A, E, or F | 0 | 0 | 0 | (Title 19 NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1 | 0| (NF) 1 5 0 1 2 5 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 125 EXAMPLE 11: 140 bed NF (free-standing) 1. Provider Number | X | X |A, E or F | 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 0| (NF) 1 4 0 1 4 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 140 | EXAMPLE #12 - 30 bed ICF/IID (free-standing) 1. Provider Number | X | X | G | 0 | 0 | 0 | (ICF/IID) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 1| (IMR) 3 0 3 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 30 | EXAMPLE #13 - 50 bed NF and ICF/IID facility Beds are distributed as follows: 30 beds - Title 19 NF 20 beds - Title 19 ICF/IID NOTE: Prepare two Forms CMS-1539 identifying the NF and ICF/IID components. 1. Provider Number | X | X |A,E,or F | 0 | 0 | 0 | (NF) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1|0 | (NF) 3 0 3 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 30 1. Provider Number | X | X | G | 0 | 0 | 0 | (IMR) 7. 12. 13. CATEGORY TOTAL FACILITY BEDS TOTAL CERTIFIED BEDS | 1| 1| (ICF/IID) 2 0 2 0 14. LTC Certified Bed Breakdown | SNF | SNF/NF | NF | ICF/IID | 20 Item 17 - Surveyor Signature The surveyor (or survey team leader) signs and dates Form CMS-1539 after ensuring that the certification documents are complete and accurate. Item 18 - State Agency Approval The authorized representative of the SA signs and dates Form CMS-1539 and forwards the certification material to the RO or SMA, as appropriate. His/her signature constitutes for Medicare the official “certification” that the information being reported is correct according to official State files. In Medicaid-only cases, the signature on this document represents the adjudicative decision of the SA on the qualifications of the institution to participate in the Medicaid program.