RO Actions Following Validation Survey

3254 - RO Actions Following Validation Survey (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) Upon receipt of survey materials, the RO analyzes and considers the SA findings and recommendations and determines whether it agrees with them. If the RO disagrees with the SA’s findings or recommendations, it may require the SA to revise the Form CMS 2567 before it is issued to the provider or supplier. The RO takes necessary action to make a compliance determination and notify the provider/supplier as soon as possible, in the case of an immediate jeopardy, and within 30 calendar days for all other cases. The RO inputs the information into ASPEN in a timely manner. In the case of a representative sample validation survey only, once the survey report is finalized the RO forwards to CO via the designated Sharepoint site a copy of the Form CMS 2567 and the accompanying correspondence to the facility. If the validation survey identifies substantial noncompliance, i.e., condition-level deficiencies, the RO removes the provider’s or supplier’s deemed status. The provider/supplier continues to be accredited by its accreditation organization and is still permitted to participate in the Medicare/Medicaid programs while correcting the deficiencies. However, until the provider/supplier either achieves substantial compliance or its Medicare agreement is terminated, it is subject to the same requirements, survey and enforcement procedures that are applied to non-accredited provider/suppliers found out of compliance following a survey. The SA monitors the provider/supplier until it reaches substantial compliance with all conditions or it is terminated from the Medicare program, and where applicable, the Medicaid program. 3254A – Providers/Suppliers Found in Compliance Following Validation Survey (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) If the provider/supplier is in compliance with all Medicare Conditions, the RO notifies the provider/supplier and sends a copy to the SA and the AO. 3254B - Providers/Suppliers Found Not In Compliance With One or More Conditions Following Validation Survey and Noncompliance Constitutes Immediate Jeopardy (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) If the SA finds deficiencies that pose an immediate jeopardy to patient’s health and safety, the SA immediately notifies the RO by phone and then forwards the survey packet to the RO within two working days after the completion of the survey. If after the RO review of the survey packet, the RO determines that there are deficiencies that pose immediate jeopardy (IJ) to patient health and safety, the provider or supplier will be placed on the 23-day termination track. See Chapter 5, section 5110.2 for detailed procedures and timeframes for substantial allegation validation surveys. In the case of a representative sample validation survey the RO removes the provider’s/supplier’s deemed status and places it under SA survey jurisdiction. The procedures and timelines in Chapter 5, Section 5110.4b apply. 3254C - Condition-level Deficiencies That Do Not Pose Immediate Jeopardy (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) If the SA determines, and the RO agrees, that the provider/supplier is out of compliance with one or more Conditions, but the deficiencies do not pose immediate jeopardy to patient health and safety, the SA and RO follow the procedures in Chapter 5, Section 5110.3 for substantial allegation validation surveys. For representative sample validation surveys, the RO removes the provider’s/supplier’s deemed status and places it under SA survey jurisdiction. The procedures and timelines in Chapter 5, Section 5110.4c apply. 3254E - Plans of Correction (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) See §2728B for discussion of the requirements for an acceptable PoC, as well as the options available to the provider/supplier. See Chapter 5, Sections 5100 – 5110 for information on when the RO must review an SA recommendation on whether or not a PoC is acceptable and when the RO must send a notice to the provider/supplier with a copy to the applicable AO(s). 3254F - Termination (Rev. 1, 05-21-04) The CMS will terminate a provider/supplier if it does not submit an acceptable PoC, or if after a reasonable period of time, it does not correct the Conditions that have been determined to be noncompliant. The RO obtains copies from the SA of the latest survey material before proceeding with termination procedures. 3254G - Compliance with All Conditions After Correction of Deficiencies (Rev. 1, 05-21-04) When an accredited provider/supplier is determined to be in compliance with all Conditions, the RO notifies the provider/supplier accordingly (and where applicable, the SMA). The RO informs the SA, in writing, to cease monitoring activities. Revisits by the SA are not authorized after an accredited provider/supplier has been notified that it is back in compliance with all Medicare Conditions, and its deemed status is reinstated.