Certification Actions Performed After the Survey

6132 - Certification Actions Performed After the Survey (Rev. 230; Issued: 07-11-25; Effective: 07-11-25; Implementation: 07-11-25) The post-survey certification processes are summarized as follows: • The surveyor completes survey documents. (See section 6136.4 “Survey Report Documentation and Data Entry”); and • The Form CMS-2567 is sent to the laboratory requesting a PoC or credible AoC, if appropriate. A PoC is required for all deficiencies, except in cases of immediate jeopardy where limitations or suspension of the certificate may be imposed prior to an opportunity for a hearing. The SA sends (e.g. emails, mails, fax) the laboratory a copy of the Form CMS-2567 within 10 working days of completing the survey. If there are citations, the SA allows the laboratory 10 calendar days to complete and return a PoC or credible AoC after receipt of the Form CMS-2567 Statement of Deficiencies. If immediate jeopardy is identified, the SA follows the time frames in section 6284. The Form CMS-2567 may be disclosed to the public in accordance with the instructions in Chapter 3, “Additional Program Activities.” Refer to the SOM Chapter 3 sections 3304, 3308, 3308A, 3310, 3312, 3314, 3316 and 3318 for information on disclosure. Information that may be disclosed to the Public by the SA: 1. Whether a facility participates in the Medicare/Medicaid/CLIA program; 2. The official CLIA report (Form CMS-2567) of a survey with the following redactions: • The name of any patient; • Medical information about any identifiable patient; • The identity of a complainant; • The address of anyone other than an owner of the facility; or • Information which could be defamatory toward any identifiable person. NOTE: The SA reviews the report of survey, and if it contains any of the above elements, it deletes the information from the report by blocking it out fully prior to release of the report. (See 42 CFR 401.118) NOTE: Prior to release, the laboratory must have had an opportunity to review the report (not exceeding 60 days) and offer comments. The disclosure must be made within 90 days following completion of the survey by the SA. 3. Citations of deficiencies that have been conveyed to the provider following a survey, except to the extent the report contains any of the identifiable information listed above. The SA blocks this information out prior to release of the statement of deficiencies; 4. PoC and pertinent comments submitted by the provider relating to CLIA deficiencies cited following a survey, except to the extent the PoC or comments contain any of the identifiable information listed above. The SA blocks this information out prior to release of the PoC; 5. Official notices of involuntary provider termination; 6. Reports and information about a laboratory’s performance in proficiency testing programs (NOTE: information about any individual person’s performance may not be released); 7. Information contained within the CMS manuals distributed to the SAs, intermediaries, carriers, providers, or suppliers; and 8. Statistical data on provider characteristics that do not identify any specific provider or individual. 9. Form CMS-116, CLIA Application for Certification; however, the tax ID must be blocked prior to the release of the application. 10. Form CMS-209, Laboratory Personnel Report (CLIA), may not be released. Paper or electronic copies of these Federal electronic documents may be released by the SA. Again, any individual identifiers (other than patient/resident or staff alphanumeric identifiers) must be deleted from the information prior to release. See section 6318 for further information on the Freedom of Information Act (FOIA). NOTE: Standard and User-Defined CASPER reports may also be released by the SA.