Condition-Level, IJ

5110.2 - Condition-Level, IJ (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) 1. IJ Removed while the SA is On-site If deficiencies pose an IJ and the IJ is removed while the SA is on-site, deficiency citations are made at the condition-level. Follow the procedure for condition-level noncompliance, non-IJ, in Section 5110.3 below. Note: The Form CMS 2567 must state at the beginning that an IJ was cited, regardless of the fact that it was removed while the SA was on-site. An entry in ASPEN/ACTS must also be made by the CMS location indicating that there was an IJ citation before the survey can be uploaded to the national database, the CMS National Reporting System (CASPER). The ASPEN/ACTS systems will prompt the CMS location whenever a survey includes condition-level deficiencies to indicate whether there was also an IJ. Details of the IJ situation and the actions taken by the provider/supplier to remove the IJ must also be documented on the Form CMS 2567. Even though the IJ was removed while the SA was on-site, the provider or supplier must still be cited for condition-level noncompliance for the applicable Condition of Participation, Condition for Coverage, or Condition for Certification that is cited for non-compliance related to the IJ. The documentation must also include the date the surveyors verified that the IJ was removed prior to completion of the survey. 2. IJ not Removed while the SA is On-site If condition-level deficiencies pose an IJ and the IJ is not removed while the SA is on- site, the SA certifies its findings in ACTS within 2 working days after the completion of the survey. If the CMS location concurs with the SA’s findings, the deemed provider/supplier is placed on a 23 calendar-day termination track. The CMS location sends the provider/supplier the Form CMS 2567, notifies the provider/supplier of the proposed termination action and effective date, which is 23 calendar days after the date of the CMS location’s notice, and requests submission of an acceptable plan of correction to the CMS location within 5 calendar days of the notice. The provider/supplier is advised it will be surveyed after receipt of an acceptable plan of correction and prior to the termination date. The notice also contains a statement that “removes” the “deemed status” of the provider/supplier and places it under SA jurisdiction. The CMS location sends a copy of the notice to the SA and a copy of the notice and Form CMS 2567 to the applicable AO(s). At the CMS location’s discretion, the materials may be sent to the AO via e-mail. Note: Although deemed status technically has been removed and the provider/supplier is placed under SA jurisdiction, because it is expected that deemed status will be restored once corrections are made and verified, no change is made in ASPEN to the provider’s/supplier’s deemed status. However, periods during which the provider/supplier is under SA jurisdiction are entered and tracked in ASPEN. Further, the AO may also conduct a survey of the facility, so long as it continues to accredit the provider/supplier under its approved Medicare accreditation program. When the CMS location receives a timely and acceptable plan of correction from the provider/supplier, it directs the SA to conduct either a full survey or an IJ follow-up survey, which is a focused, revisit-type survey, before the scheduled termination date in order to confirm that the IJ has been removed and that the provider/supplier is in substantial compliance. See Section 5110.3 for a discussion of factors the CMS location should consider when deciding whether a full survey is needed. If the CMS location authorizes a full survey, see Section 5110.4 for procedures to follow, except that the full survey must be conducted prior to the 23-day termination date. i. No Acceptable Plan of Correction Submitted No revisit is necessary if the provider/supplier fails to submit a timely and acceptable plan of correction. CMS will proceed to terminate a provider/supplier if it does not submit a timely and acceptable POC. See SOM Section 3254F. The public notice must be published 15 calendar days prior to the termination date. The CMS location notifies the applicable Medicare Administrative Contractor (MAC) via the Form CMS 2007 of the termination of the provider/supplier’s Medicare agreement, including the effective date of the termination. 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. The CMS location sends a copy of the termination letter to the applicable AO(s). At the CMS location’s discretion, the copy may be sent to the AO via e-mail. ii. Post-IJ First Revisit: IJ Not Removed At least 5 calendar days in advance of the scheduled termination date, the SA certifies to the CMS location in ACTs its findings, based on on-site verification, that the IJ has not been removed, and recommends that the termination action proceed. The CMS location reviews the SA’s findings, and if it concurs with the SA’s recommendation, 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 the CMS National Reporting System (CASPER). The termination of the provider’s/supplier’s Medicare agreement is processed in ASPEN. The CMS location sends the provider/supplier a final termination letter and publishes a public notice, in accordance with the termination process in Section 3010B. The provider/supplier is terminated from the Medicare program. The CMS location notifies the applicable Medicare Administrative Contractor (MAC) via the Form CMS 2007 of the termination of the provider/supplier’s Medicare agreement, including the effective date of the termination. The CMS location sends a copy of the termination notice and the Form CMS 2567 to the applicable AO(s). At the CMS location’s discretion, the materials may be sent to the AO via e-mail. iii. Post-IJ First Revisit: IJ Removed, Substantial Compliance The termination action is rescinded if the IJ has been removed and substantial compliance has been achieved prior to the effective date of the termination, i.e., there are no condition-level deficiencies identified during the follow-up survey by the SA. The SA certifies its findings to the CMS location via ACTS at least 5 calendar days in advance of the scheduled termination date, and recommends that the termination action be rescinded. 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. If the CMS location concurs, and in all other cases where the Form CMS 2567 is not reviewed by the CMS location, 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 finding, 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 substantial noncompliance. When substantial compliance is achieved, the CMS location either issues a notice, or authorizes the SA in ACTS to issue the provider/supplier a notice of its compliance status, restoring its deemed status. The CMS location or SA, as applicable, issues this notice to the provider/supplier, along with a copy of the Form CMS 2567 containing the survey findings. In addition, the CMS location sends a copy of the notice letter to the applicable AO(s). At the CMS location’s discretion, the copy may be sent to the AO via e- mail. Although the follow-up survey found the provider/supplier to be in substantial compliance, it may have resulted in citation(s) of standard-level deficiencies of the Form CMS 2567. Because deemed status has been restored, the provider/supplier is not obligated to submit a plan of correction to the SA, nor are any further revisits conducted. The provider/supplier may voluntarily choose to submit a plan of correction because the Form CMS 2567 will be made available to the public. The SA and CMS location do not review any plan of correction the provider/supplier submits; no further revisit survey is conducted. iv. Post-IJ First Revisit: IJ Removed, Substantial Noncompliance Remains If the IJ has been removed but substantial noncompliance (i.e., condition-level deficiencies), remain, the SA certifies its findings to the CMS location in ACTS within 10 working days after the survey completion date. The SA certifies that the IJ has been removed and recommends rescission of the 23 calendar-day IJ termination action, but continuation of the termination action on a 90 calendar- day termination track. The CMS location reviews the SA’s findings, and if it concurs with the SA’s recommendation, the CMS location gives the provider/supplier up to 67 additional calendar days, or a total of 90 calendar days (23 plus 67) to achieve substantial compliance. The resulting revised termination date is 90 calendar days after the date of the CMS location’s original 23-day notice. The CMS location sends the CMS Form 2567 from the follow-up survey to the provider/supplier with notice of the new termination date, and requests that an acceptable POC be provided to the SA within 10 calendar days of the notice. Post-IJ Second Revisit: The SA conducts the second revisit survey by the 60th calendar day after the date of the CMS location’s original 23-day termination notice. Unlike the post-IJ first revisit survey, advance authorization from the CMS location is not required. (i) Post-IJ Second Revisit Survey Findings: Substantial Compliance The termination action is rescinded if substantial compliance (i.e., no condition-level deficiencies) is achieved and documented through the onsite verification at the revisit survey. There may or may not be standard-level deficiencies cited. Within 10 working days after the completion of the revisit survey, the SA certifies to the CMS location its findings via ACTS and recommends that the termination action be rescinded. The CMS location randomly selects some Form CMS 2567s with only standard-level deficiencies for review, to determine if the CMS location concurs with the SA’s finding of substantial compliance. If the CMS location concurs, and in all other cases where the Form CMS 2567 is not reviewed by the CMS location, 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 the CMS location uploads the complaint survey package into CASPER, the CMS National Reporting System. If the CMS location does not concur, the CMS location discusses with the SA revisions needed on the Form CMS 2567 and, after the revisions are made, follows the procedures for substantial noncompliance. The CMS location either issues a notice, or authorizes the SA in ACTS to issue a notice to the provider/supplier of its compliance status and that its deemed status is restored. The CMS location or SA, as applicable, issues this notice to the provider/supplier, along with a copy of the Form CMS 2567 with the survey findings. The CMS location sends a copy of the notice and Form CMS 2567 to the applicable AO(s). At the CMS location’s discretion, the materials may be sent to the AO via e-mail. i. Post-IJ Second Revisit Survey Findings: Substantial Noncompliance If the second revisit shows that the provider/supplier fails to demonstrate substantial compliance (i.e., condition-level deficiencies are identified through on-site verification by the SA), the SA certifies to the CMS location its findings within 10 calendar days after the survey completion date, and recommends that the termination action proceed. The CMS location reviews the SA’s findings, and if it concurs with the SA’s recommendation, the CMS location sends the provider/supplier a final termination letter and publishes a public notice 15 calendar days prior to the termination date. The provider/supplier is terminated from the Medicare program. The CMS location notifies the applicable Medicare Administrative Contractor (MAC) via the Form CMS 2007 of the termination of the provider/supplier’s Medicare agreement, including the effective date of the termination. 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 provider’s or supplier’s Medicare agreement is terminated in ASPEN. The CMS location sends a copy of the final termination notice and Form CMS 2567 to the applicable AO(s). At the CMS location’s discretion, the materials may be sent to the AO via e-mail.