Forwarding Report of Investigation to the CMS location

5450 - Forwarding Report of Investigation to the CMS location (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) Transmit the results of the investigation and your recommendations to the CMS location through ACTS within 10 working days following completion of the onsite survey, if it appears there may be an EMTALA violation. If there appears to be no violation, this time frame may be extended to 15 working days, in order to allow the SA additional processing time. Transmit the following materials to the CMS location through ACTS: • Form CMS-562,”Medicare/Medicaid/CLIA Complaint Form;” • Form CMS-1541B, “Responsibilities of Medicare Participating Hospitals in Emergency Cases Investigation Report.” Recommend one or more of the actions below on the form: o None - This means the complaint was not substantiated; o In Compliance, but Previously Out of Compliance - This means that the hospital identified the problem on its own and took effective corrective action prior to the investigation. In addition to this recommendation, document on the Form CMS-2567 when the hospital identified the violation or a similar problem, the corrective action taken, and the date of such action. Also, document that the hospital has had no violations or similar problems for at least the past 6 months; o Recommend Termination (23 calendar day track) - This means that the hospital is out of compliance with 42 CFR 489.24 or the related requirements at 42 CFR 489.20(l), (m), (q) or (r) and the violation presents an immediate jeopardy to patient health and safety; o Recommend Termination (90 calendar day track) - This means that the hospital is out of compliance with 42 CFR 489.24 or the related requirements at 42 CFR 489.20(l), (m), (q) or (r), but the violation does not present an immediate jeopardy to patient health and safety; o Request Physician Review. This means that it is recommended that the CMS location obtain a medical review of the case; o Possible Discrimination. This means that it is believed that discrimination occurred based on financial status, race, color, nationality, handicap, or diagnosis. • Form CMS-670, “Survey Team Composition and Workload Report;” • Form CMS-2567, “Statement of Deficiencies and POC;” NOTE: If the hospital had identified the deficiency and took corrective action prior to the investigation, indicate on the Form CMS-2567 that the requirement was not met. However, indicate on the Form CMS-2567 and the narrative report that the hospital took corrective action prior to the investigation, what action was taken, and for how long the hospital has been in compliance. • Physician Review Outline for Emergency Care Obligations of Medicare Hospital (if physician review was done by SA); • Complaint investigation narrative; • Copies of pertinent hospital policies and procedures that relate to the identified deficiencies; • Summary listing of all patients comprising the sample, including an explanation of how and why the cases were selected for review; • Summary of interviews. Transmit the following to the CMS location by overnight mail: • Copies of medical records for substantiated cases, medical records of individuals named in the complaints, and other medical records for which a QIO review is requested; • Certification of benefits versus risks of the transfer, if this is a transfer case.