Data Entry

5060.1 - Data Entry (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) The SAs and CMS locations are required to enter into ACTS: • All complaints gathered as part of Federal survey and certification responsibilities, regardless if an onsite survey is conducted [i.e., complaints related to noncompliance with the Federal condition(s) of participation (COPs), condition(s) for coverage (CFCs), condition(s) for certification, requirement(s) for participation (RFPs), or EMTALA requirement(s)]; and • For nursing homes, all self-reported incidents that are reported under Federal law and the requirements for participation [i.e., reporting to law enforcement of crimes occurring in LTC facilities – §1150B of the Social Security Act and §483.12(b)(5); alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property – §483.12(c)(1) and (4)]. For non-long term care providers/suppliers, all self- reported incidents that require a Federal onsite survey. The information recorded in ACTS reflects the allegation furnished by the complainant/provider/supplier at the time of the intake. At a minimum, if the intake information requires an onsite survey and the allegation may involve both Federal and State licensure requirements, a Federal onsite survey is completed and entered into ACTS. If an investigation finds one or more violations of Federal requirements, the findings must be cited under the appropriate tags and entered into the Federal system even if the information is entered into a State licensure data system. Since this information is essential to the effective management of the survey and certification program, it is important that SAs complete the required fields in ACTS in a timely manner. Exhibit 23 defines the required fields in ACTS. Tracking of Referrals in ACTS The SAs are required to enter into ACTS all referrals from public entities that allege noncompliance with the Federal requirements. For reporting purposes, the SAs should enter these cases as complaints (i.e., Intake Type=Complaint, Intake Subtype=Federal COPs, CFCs, RFPs, EMTALA). In order to more quickly identify which of these cases stem from a referral, the SAs are expected to check the appropriate category under the “Source” field. For example, for referrals from the coroner’s office, states would check “Coroner” under the “Source” field for the intake. Tracking of State Monitoring Visits (See Section 5077) in ACTS When a State Monitoring Visit results in a Federal deficiency, the SA will identify the survey in ASPEN as “complaint” and create an intake and survey record in ACTS. The data should be entered into ACTS as follows: • Intake Type = Complaint; • Intake Subtype = Federal COPs, CFCs, RFPs, EMTALA; • Source = State SA; • Priority = can vary; and • Allegation Type = State Monitoring.