When No Immediate Jeopardy Exists and an Opportunity to

7305.1.1 – When No Immediate Jeopardy Exists and an Opportunity to Correct Will be Provided Before Remedies Are Imposed (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) When no immediate jeopardy exists and an opportunity to correct will be provided before remedies are imposed, the surveying entity sends out an initial notice notifying the facility of the following (and the State sends a copy of this notice to the State Medicaid Agency and the CMS Location): a. Transmits deficiencies cited (those listed on the Form CMS-2567, as well as those isolated deficiencies which cause no harm and potential for only minimal harm); b. Provides notice of the mandatory remedy which must be imposed if the facility fails to achieve substantial compliance at 6 months, (i.e., termination of provider agreement and consequent cessation of payments); c. Provides that the approved plan of correction will establish the outside date by which correction must be made. d. May serve as the formal notice of the imposition of any category 1 remedy, as authorized by CMS or the State Medicaid Agency, to be effective on (date the State expects correction based on the outside correction date on the facility’s approved plan of correction, but no earlier than 15 calendar days from date of receipt of notice by the facility). Also, if authorized by the CMS Location, the State may provide formal notice to the facility of imposition of denial of payment for new admissions in the initial notice rather than in the first revisit letter, to be effective on (date the State expects correction based on the outside correction date on the facility’s approved plan of correction) but in no case later than 3 months from the date of the survey if the facility fails to achieve substantial compliance; (See also §7301, §7314, §7316.2, and §7506.1.) e. Provides that the State’s proposed remedies will be forwarded to CMS and/or the State Medicaid Agency if correction is not achieved at the first revisit. Civil money penalties will be effective as of the date that noncompliance began, usually the date of the survey (see also §7518). All other remedies can be imposed as soon as the 15-day notice requirement is met. The remedies for which the State has provided notice, as authorized by CMS and the State Medicaid Agency, will take effect without further notice from the CMS Location or State Medicaid Agency; f. Provides that an acceptable plan of correction is required in response to deficiencies listed on the Form CMS-2567 and must be received within 10 calendar days of the facility’s receipt of the CMS2567 (see §7317). The plan of correction will serve as the facility’s allegation of compliance; g. Informs the facility of the opportunity for informal dispute resolution; h. Specifies that if an acceptable plan of correction is not received within 10 calendar days of the facility’s receipt of the CMS-2567, the State will notify the facility that it is recommending to the CMS Location and/or the State Medicaid Agency that remedies other than category 1, and/or denial of payment for new admissions, be imposed effective as soon as notice requirements are met. As authorized by CMS and/or the State Medicaid Agency, formal notice of imposition of category 1 remedies may be officially provided in this initial notice, and notice of imposition of denial of payment for new admissions may be officially provided in this notice or in the first revisit letter; (See also §7301, §7314, §7316.2, and §7506.1.) i. Provides elements of an acceptable plan of correction (See §7317); j. Informs the facility of the disapproval of its nurse aide training and competency evaluation program and competency evaluation program, as well as its appeal rights if the program loss is based on a finding of substandard quality of care (see §7809); and k. Provides that when substandard quality of care is determined, the facility must provide a list of physicians for residents identified with substandard quality of care on the survey. The State must notify each physician and refer the administrator to the State’s licensing board. (See also §7310 and §7320). l. When no formal notification of remedies is being provided in this initial notice, the following language will be inserted in bold type in the letter to make it clear that the initial notice is not the notice that triggers the imposition of remedies and that any such determination will be provided in a separate notice: “Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement. If it is determined that termination or any other remedy is warranted, you will be provided with a separate formal notification of that determination.”