Adverse Actions - General

3000 - Adverse Actions - General (Rev. 1, 05-21-04) 3000A - Applicability (Rev. 1, 05-21-04) The Regional Office (RO) and State survey agency (SA) follow the procedures in this part if an adverse action is likely to be initiated against Medicare participating providers and suppliers. Because many Medicare providers and suppliers also participate in the Medicaid program and Federal procedures must also be followed when surveying and certifying providers that only participate in the Medicaid program, these procedures generally apply to both programs. Exceptions for Medicaid are noted. (See also Chapter 7 for specifics pertaining to SNFs and NFs.) For Medicaid-only facilities, termination procedures are not State plan requirements. However, a State risks disallowance of Federal matching funds for failure to use Federal standards and the forms, methods, and procedures prescribed by CMS. (See 42 CFR 442.30.) 3000B - State Ombudsman Programs (Rev. 1, 05-21-04) To coordinate with the State ombudsman network, the SA should establish procedures to: • Notify the State ombudsman of decisions to initiate proceedings to terminate, or nonrenew a provider agreement; • Notify the State ombudsman of voluntary terminations and planned terminations, including dates of closure; • Consider ombudsman information about situations in the facility and the credibility of the provider’s allegations of compliance; and • Share Statements of Deficiencies and Plans of Correction (PoCs). 3000C - CMS Authority to Terminate Medicare and Medicaid Participation (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 1. Noncompliance with Conditions of Participation (CoPs), Conditions for Coverage, or Requirements for SNFs - The RO is delegated authority to terminate Medicare participation of any certified provider or supplier because of noncompliance with the applicable regulatory requirements, or Conditions of Participation (CoPs) or Conditions for Coverage (CfCs). 2. Violations of Medicare Provider Agreements or certified Supplier Approvals, Quality Improvement Organization (QIO) Sanctions, or Program Abuse - The Secretary’s authority to terminate provider agreements or certified supplier approvals is delegated to the Associate Regional Administrator and may be redelegated to the RO Branch Chief, but other components may also be authorized to find that termination is in order. Accordingly, the RO processes terminations on grounds other than noncompliance with the CoPs. See §3032. 3. “Look Behind” Cancellation of Medicaid Intermediate Care Facility/Individuals with Intellectual Disabilities (ICF/IID) Agreements - The ROs are authorized to cancel the approval of an ICF/IID to participate in the Medicaid program when the ICF/IID fails to comply substantially with the applicable CoPs. (See §1910(b) of the Act.) 4. Termination of Nursing Facility (NF) Medicaid Agreements - The ROs are, under certain circumstances, authorized to terminate a NF’s participation in the Medicaid program. (See §1919(h) of the Act and Chapter 7 of the SOM.)