Substantial Compliance

5110.1 - Substantial Compliance (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) If a condition-level deficiency is not cited at a survey, the provider/supplier is in substantial compliance with the Federal requirements. The SA certifies its survey findings in ACTS within 30 calendar days after the completion of the survey. A Form CMS 2567 is prepared in all cases. Even if no deficiencies were cited, the Form CMS 2567 is issued with a statement that a survey was conducted to evaluate compliance with the listed requirements identified on the CMS-2802 and that no deficiencies were identified in these areas. The CMS location randomly selects several Form CMS 2567s with standard-level deficiencies for review to determine if the CMS location concurs with the SA’s finding of substantial compliance. • For all cases not selected for review of the Form CMS 2567, the CMS location completes the processing in ACTS of the complaint investigation Form CMS 562 and other applicable items in ACTS, and then, depending on CMS location practice, either the SA or CMS location uploads the complaint survey package into CASPER, the CMS National Reporting System. • For cases selected for review of the Form CMS 2567: • If the CMS location concurs with the finding, the CMS location completes the processing in ACTS of the complaint investigation Form CMS 562 and other applicable items in ACTS, and then, depending on CMS location practice, either the SA or CMS location uploads the complaint survey package into CASPER, the CMS National Reporting System. • If the CMS location does not concur with the SA’s findings of substantial compliance, the CMS location discusses with the SA any revisions needed on the Form CMS 2567 and, after the revisions are made, follows the procedures for a survey finding substantial noncompliance. (See Section 5110.2 or 5110.3, as applicable.) The CMS location either issues a notice or authorizes the SA in ACTS to issue the provider/supplier a notice of its compliance status. The CMS location or SA, as applicable, issues this notice to the provider/supplier, along with a copy of the Form CMS 2567containing the survey findings. The notice indicates that the provider/supplier was found to be in substantial compliance even though there may, or may not, also be standard-level deficiencies cited. In such circumstances, the provider/supplier is not required to submit a plan of correction for any cited standard-level deficiencies, but may choose to do so because the Form CMS 2567 is available to the public. The SA and CMS location do not review any plan of correction the provider/supplier submits; no revisit survey is conducted. The CMS location promptly sends a copy of the notice letter and Form CMS 2567 to the applicable AO(s). At the CMS location’s or SA’s discretion, the materials may be sent to the AO via e-mail.