Full Survey after Complaint Survey with Condition-level

5110.4 - Full Survey after Complaint Survey with Condition-level Deficiencies, When Authorized by the CMS location (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) If the CMS location authorizes the SA to conduct a full survey after the complaint survey, the timeframes and procedures described in this section apply. Timeframe The full survey must be conducted within: • 23 days after the CMS location’s notice to the provider/supplier, if the complaint survey involved an IJ that was not removed while the survey team was on-site; or • 60 calendar days after the CMS location’s notice to the provider/supplier in all other cases. Procedures following the full survey with findings of: a) Full Survey Findings: Substantial Compliance If the SA full survey finds the deemed provider or supplier to be in substantial compliance, the SA and CMS location follow the same procedures and timeline as at Section 5110.1. In addition, since the CMS location had removed deemed status, the CMS location either issues a notice, or authorizes the SA to issue a notice to the provider or supplier of its compliance status and that its deemed status is restored, 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. b) Full Survey Findings: Condition-Level, IJ 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 5110.4c 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 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 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 or Condition for Coverage 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 to the CMS location 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 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. When the CMS location receives a timely and acceptable plan of correction from the provider/supplier, it directs the SA to conduct an IJ follow-up survey before the rescheduled termination date in order to confirm that the IJ has been removed and that the provider/supplier complies with the conditions previously cited for noncompliance. 2.1 First Revisit after Full Survey with IJ 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 SA and CMS location complete the processing in ASPEN of the survey kit 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. First Revisit Survey Findings: IJ Not Removed At least 5 calendar days in advance of the scheduled termination date, the SA certifies to the CMS location 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 SA and CMS location complete the processing of the survey kit in ASPEN and then, depending on CMS location practice, either the SA or CMS location uploads the 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 or 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. First Revisit Survey Findings: 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 first revisit survey by the SA. The SA certifies its findings to the CMS location 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, depending on CMS location practice, either the SA or CMS location uploads the 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 to issue the provider/supplier a notice of its compliance status, restoring its deemed status, along with a copy of the Form CMS 2567containing 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 revisit 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 or supplier is not obligated to submit a plan of correction to the SA, nor are any further revisits conducted. The provider or 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. First Revisit Survey Findings: IJ Removed, Substantial Noncompliance Remains If the IJ has been removed but substantial noncompliance (i.e., condition-level deficiencies), remains, the SA certifies its findings to the CMS location within 10 working days after the survey completion date. If the CMS location concurs that the IJ has been removed but that condition-level deficiencies remain, the CMS location considers whether the survey findings warrant a second revisit or proceeding immediately to termination. At this point the provider/supplier will have been surveyed three times, including the preceding complaint survey, with continued substantial noncompliance found in each survey and at least one IJ. Generally the CMS location authorizes a second revisit, but the CMS location has discretion to make an exception, based on the facts of the case, including the risks to patients associated with the remaining deficiencies versus providing the provider/supplier further opportunity to correct its problems in a timely manner. If the CMS location does not authorize a second revisit, it follows the procedures in paragraph ii above. If the authorizes a second revisit, the CMS location gives the provider/supplier up to 67 additional calendar days, or a total of 90 calendar days (23 plus 67) from the date of the notice of the IJ, to achieve substantial compliance. The resulting revised termination date is 90 calendar days after the date of the CMS location’s original 23-day termination notice. The CMS location provides the provider/supplier the Form CMS 2567 for the revisit 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. 2.2 Second Revisit after Full Survey with IJ The SA conducts the second revisit survey no later than 60 calendar days after the date of the CMS location’s 23-day termination notice to the provider or supplier. 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) during the second revisit survey, the SA certifies its findings to the CMS location 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 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, depending on CMS location practice, either the SA or CMS location uploads the survey kit 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 also either issues a notice, or authorizes the SA to issue the provider/supplier a notice, of its compliance status and that its deemed status is restored, 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 shows that substantial noncompliance (i.e., condition-level deficiencies) remain, 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 or supplier a final termination letter and publishes a public notice 15 calendar days prior to the termination date. The provider or 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 SA and CMS location complete the processing in ASPEN of the survey kit and, depending on CMS location practice, either the SA or CMS location uploads the 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. c) Full Survey Findings: Condition-Level, Non-IJ If the results of the full survey indicate there is substantial noncompliance (i.e., condition- level deficiencies), but the deficiencies do not constitute an IJ, the SA certifies its findings to the CMS location 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 places the provider or supplier on a 90 calendar-day termination track as a result of the full survey. The CMS location sends the provider or supplier the Form CMS 2567 and notifies it 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 of the notice. Additionally, the CMS location sends a copy of the notice of termination letter to the applicable AO(s). 1. First Revisit: The SA conducts the first revisit survey no later than the 45th calendar day after the date of the CMS location’s termination notice to the provider or supplier. i. 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 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 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 of the survey kit in ASPEN and then, depending on CMS location practice, either the SA or the CMS location uploads the 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 to issue a notice to the provider or supplier of its compliance status and that its deemed status is restored, 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. ii. First Revisit Survey Findings: Substantial Noncompliance If the SA confirms 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 concurs that condition-level deficiencies remain, the CMS location considers whether the survey findings warrant a second revisit or proceeding immediately to termination. At this point the provider/supplier will have been surveyed three times, including the complaint survey, the full survey and the first revisit, with substantial noncompliance found on each survey. Generally the CMS location authorizes a second revisit, but the CMS location has discretion to make an exception, based on the facts of the case, including the risks to patients associated with the remaining deficiencies versus providing the provider/supplier further opportunity to correct its problems in a timely manner. If the CMS location does not authorize a second revisit, the CMS location and SA will follow the procedures outlined in paragraph 2(ii). below. If the CMS location authorizes a second revisit, 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. 2. Second Revisit: The SA conducts the second revisit survey no later than 60 calendar days after the date of the termination notice to the provider or supplier. (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) during the second revisit survey, the SA certifies its findings to the CMS location 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 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 ASPEN of the survey kit and then, depending on CMS location practice, either the SA or CMS location uploads the complaint and revisit surveys 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 also either issues a notice, or authorizes the SA in ACTS to issue the provider or supplier a notice, of its compliance status and that its deemed status is restored, 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 shows that the provider or supplier has substantial noncompliance (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 or 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 ASPEN of the survey kit and then, depending on CMS location practice, either the SA or CMS location uploads the 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.