When No Immediate Jeopardy Exists and No Opportunity to

7305.1.2 – When No Immediate Jeopardy Exists and No 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 no opportunity to correct will be provided before remedies are imposed, the surveying entity sends an initial notice which: 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 provider agreement termination that must be imposed if the facility has not achieved substantial compliance 6 months from the last day of the survey that found the noncompliance; c. May provide that this notice serves as a formal notice of the imposition of denial of payment for new admissions and/or any category 1 remedy, as authorized by CMS and/or the State Medicaid Agency, to be effective no sooner than 15 calendar days from date of receipt of this notice by the facility, but in no case later than 3 months from the date of the survey; (See also §7314 and §7506.1.) d. Provides than 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 CMS-2567. The plan of correction will serve as the facility’s allegation of compliance; e. Informs the facility of the opportunity for an informal dispute resolution; f. Specifies that when an acceptable plan of correction is not submitted within 10 calendar days, the State may propose to the CMS Location and/or State Medicaid Agency that remedies be imposed immediately within applicable notice requirements; g. 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; h. 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; i. Provides elements of an acceptable plan of correction. (See §7317) and, j. 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 a 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.”