Condition-Level, Non-IJ

5110.3 - Condition-Level, Non-IJ (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) If the provider/supplier fails to demonstrate substantial compliance, i.e., condition-level deficiencies are identified by the SA, but they do not pose an IJ, the SA certifies its findings to the CMS location via ACTS within 10 working days after the survey completion date. The CMS location reviews the SA’s findings, and if it concurs with the SA’s recommendation, the CMS location either places the deemed provider/supplier on a 90 calendar-day termination track or it requires a full survey after a complaint survey. In determining whether to exercise its discretion to require a full survey for deemed providers and suppliers, the CMS location may consider factors including, but not limited to, the following: • The manner and degree of noncompliance identified as a result of the complaint investigation; • The provider’s/supplier’s compliance history; • Recent changes in the provider’s/supplier’s ownership or management; • The length of time since the provider’s/supplier’s last accreditation survey; • The availability of SA resources at the time required to conduct a full survey; and/or • The advantages associated with conducting a more extensive survey compared to the advantages associated with the faster enforcement (and thus a faster potential corrective action) that result when proceeding directly to enforcement action after the complaint survey. Paragraph a) below discusses the procedures when the CMS location does not require a full survey after the complaint survey; paragraph b) discusses the procedures to follow when the CMS location directs the SA to conduct a full survey. a) No full survey – proceed directly to termination track based on the complaint survey If the CMS location places the deemed provider/supplier on a 90 calendar-day termination track as a result of the complaint investigation, it sends the provider/supplier the Form CMS 2567, notifies the provider/supplier of the proposed termination action and effective date, which will be 90 calendar days after the date of the CMS location’s notice. The CMS location requests submission of an acceptable plan of correction to the SA within 10 calendar days. 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 has technically 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. The SA conducts a complaint survey revisit after the SA has received a timely and acceptable plan of correction, but no later than the 45th calendar day after the notice to the provider/supplier. 1) No Timely, Acceptable Plan of Correction Submitted If the provider/supplier fails to submit a timely and acceptable plan of correction to the SA and as a result the SA is unable to conduct a timely revisit before the termination date, the SA notifies the CMS location and the CMS location may proceed with termination. See SOM Section 3254F. The CMS location publishes a public notice 15 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 approves 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 provider’s or supplier’s Medicare agreement is terminated in ASPEN. Additionally, the CMS location sends a copy of the notice of termination letter to the applicable AO(s). 2) First 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 first 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 in ACTS its findings 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. • 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 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. 3) First Revisit Survey Findings: Substantial Noncompliance If the SA finds during the first revisit survey that the provider/supplier is not in substantial compliance with one or more Medicare conditions, the SA consults with the CMS location on its findings and whether to conduct a second revisit. If the CMS location agrees that condition-level deficiencies remain, the CMS location considers whether the survey findings warrant a second revisit or proceeding immediately to termination. Generally the CMS location authorizes a second revisit, but the CMS location has discretion to make an exception, based on the facts of the situation. For example, if the SA and CMS location determine that an immediate jeopardy was present during the first revisit, the CMS location might find it prudent to proceed to termination without a second revisit. If the CMS location agrees that condition-level deficiencies remain and does not authorize a second revisit, the CMS location and SA follow the procedures outlined in paragraph 3ii. below. If a second revisit is authorized by the CMS location, the SA sends the provider/supplier the Form CMS 2567 for the first revisit with notice that substantial noncompliance remains, the 90-day termination date remains in effect, a new acceptable plan of correction is required, and that an additional revisit will be conducted prior to the termination date. The SA conducts the second revisit no later than 60 calendar days after the date of the termination notice. i. Second Revisit Survey Findings: Substantial Compliance If substantial compliance is achieved by the provider/supplier (i.e., no condition-level deficiencies are identified through the on-site verification by the SA), the SA certifies its findings to the CMS location via ACTS within 10 working days after the survey completion date, 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, 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, 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 the provider/supplier a notice letter of its compliance status and that its deemed status is restored. The CMS location or SA, as applicable, forwards this notice to the provider/supplier, along with a copy of the Form CMS 2567 with the survey findings. Additionally, the CMS location sends a copy of the 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. ii. Second Revisit Survey Findings – Substantial Noncompliance If the second revisit survey 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 its findings to the CMS location via ACTS 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 at least 15 calendar days prior to the termination date, consistent with the requirements of Section 3012. 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 CMS National Reporting System. The provider’s or supplier’s Medicare agreement is terminated in ASPEN. Additionally, 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. b) Full Survey After the Complaint Survey If the CMS location directs the SA to conduct a full survey following the complaint survey, it sends the Form CMS 2567 for the complaint survey to the provider/supplier in addition to a notice letter indicating that it is “removing” the provider’s/supplier’s deemed status and that a full survey will be conducted on an unannounced basis. The provider/supplier is not required to submit a plan of correction in response to the complaint survey findings, but may choose to do so. 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. Additionally, the CMS location sends a copy of the notice letter and Form CMS 2567 for the complaint survey 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, since it continues to accredit the provider/supplier. The full survey must be conducted within 60 calendar days after the CMS location’s notice to the provider/supplier of the complaint survey results and removal of deemed status. The CMS location and SA follow the procedures in Section 5110.4.