CMS State Operations Manual Flashcards
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Questions and Answers

If a facility is in noncompliance and IJ does NOT exist, CMS or the State may impose either a per day civil money penalty between _____ per day.

$50 - $3,000

If a facility is in noncompliance and IJ does NOT exist, CMS or the State may impose a 'per instance' civil money penalty between _____ for each deficiency.

$1,000 - $10,000

In what situations will CMS impose federal remedies and identify the survey as a 'No Opportunity to Correct'?

  1. IJ (scope and severity levels J, K, and L); 2. G, H, or I deficiencies that fall into Substandard Quality of Care; 3. G or above deficiencies on the current survey AND G or above deficiencies on the previous standard health or LSC survey OR G or above on any type of survey between the current survey and the last standard health or LSC survey; 4. A facility is classified as a SFF AND has a deficiency at level F or higher for the current health survey or G or higher for the current LSC survey.

Directed in-service training remedies can be imposed when the facility has deficiencies where there are ____.

<p>Knowledge gaps in standards of practice, staff competencies, or the minimum requirements of participation and where education is likely to correct the noncompliance.</p> Signup and view all the answers

What is a plan developed by either the State or CMS that details actions the facility must take to address noncompliance?

<p>Direct Plan of Correction</p> Signup and view all the answers

What is the term for the temporary appointment by CMS or the State of a substitute facility manager or administrator?

<p>Temporary Management</p> Signup and view all the answers

____ will be imposed when a facility is not in substantial compliance 3 months after the last day of the survey identifying deficiencies.

<p>Mandatory denial of payment for new admissions (DPNA)</p> Signup and view all the answers

____ has the authority to deny all payment for Medicare and/or Medicaid residents.

<p>CMS</p> Signup and view all the answers

What factors are used to determine the use of denial of payment for all Medicare and Medicaid residents?

<ol> <li>Seriousness of current survey findings; 2. Noncompliance history of the facility; 3. Use of other remedies that have failed to achieve or sustain compliance.</li> </ol> Signup and view all the answers

What is the role of a state monitor in a facility?

<p>A state monitor oversees the correction of cited deficiencies in the facility as a safeguard against further harm to residents when harm or a situation with a potential for harm has occurred.</p> Signup and view all the answers

____ will be imposed when a facility has been cited with substandard quality of care deficiencies on the last 3 consecutive standard health surveys.

<p>State Monitoring</p> Signup and view all the answers

____ can impose a State's ban on admissions remedy only with regard to all Medicare/Medicaid residents. Only ____ can ban admissions of private pay residents.

<p>CMS; the State</p> Signup and view all the answers

The State must forward the form CMS-2567 to the facility by no later than the ____ after the last day of the survey.

<p>10th working day</p> Signup and view all the answers

The facility must submit its plan of correction by ____.

<p>The 10th calendar day after the facility receives form CMS-2567</p> Signup and view all the answers

What are the requirements for an acceptable plan of correction?

<ol> <li>Must address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; 2. Must address how the facility will identify other residents having the potential to be affected by the same deficient practice; 3. Must address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur; 4. Must indicate how the facility plans to monitor its performance to make sure that solutions are sustained; 5. Must include dates when corrective action will be completed.</li> </ol> Signup and view all the answers

Surveyors will complete a mandatory onsite revisit when a facility's beginning survey finds deficiencies that constitute substandard quality of care, harm, or IJ.

<p>True</p> Signup and view all the answers

Remedies can be imposed only at certain times for specific levels of noncompliance.

<p>False</p> Signup and view all the answers

Onsite revisits can be conducted at any time for any level of noncompliance.

<p>True</p> Signup and view all the answers

If a facility is in substantial compliance, but has deficiencies that are isolated with no actual harm and potential for only minimal harm, the facility will receive ____.

<p>A Notice of Isolated Deficiencies Which Cause No Actual Harm With the Potential for Minimal Harm (Form A)</p> Signup and view all the answers

A plan of correction is NOT required for ____.

<p>A Notice of Isolated Deficiencies Which Cause No Actual Harm With the Potential for Minimal Harm (Form A)</p> Signup and view all the answers

What are the 3 expectations established by the nursing home reform regulation?

<ol> <li>Providers remain in substantial compliance with Medicare/Medicaid program requirements as well as state law; 2. All deficiencies will be addressed promptly; 3. Residents will receive the care and services they need to meet their highest practicable level of functioning.</li> </ol> Signup and view all the answers

What is the abbreviation for a survey that gathers information through resident-centered techniques on facility compliance?

<p>Abbreviated Standard Survey</p> Signup and view all the answers

What is the definition of Abuse in the context of nursing facilities?

<p>The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.</p> Signup and view all the answers

What does CASPER stand for?

<p>Certification and Survey Provider Enhanced Reporting</p> Signup and view all the answers

What is meant by Certification of Compliance?

<p>The facility is in at least substantial compliance and is eligible to participate in Medicaid as a nursing facility, or in Medicare as a skilled nursing facility, or in both programs as a dually participating facility.</p> Signup and view all the answers

What is the definition of Certification of Noncompliance?

<p>The facility is not in substantial compliance and is not eligible to participate in Medicaid as a nursing facility, or in Medicare as a skilled nursing facility, or in both programs as a dually participating facility.</p> Signup and view all the answers

What denotes a Deficiency in a skilled nursing facility?

<p>A skilled nursing facility's or nursing facility's failure to meet a participation requirement specified in the Social Security Act or in 42 CFR Part 483 Subpart B.</p> Signup and view all the answers

What does DoPNA stand for?

<p>Denial of Payment for New Admissions</p> Signup and view all the answers

What does DPoC stand for?

<p>Directed Plan of Correction</p> Signup and view all the answers

What defines a Dually Participating Facility?

<p>A facility that has a provider agreement in both the Medicare and Medicaid programs.</p> Signup and view all the answers

What is meant by Enforcement Action?

<p>The process of imposing one or more remedies such as termination of a provider agreement, denial of participation, or denial of payment for new admissions.</p> Signup and view all the answers

What is an Expanded Survey?

<p>An increase beyond the core tasks of a standard survey due to suspected substandard quality of care.</p> Signup and view all the answers

What is an Extended Survey?

<p>A survey that evaluates additional participation requirements subsequent to finding substandard quality of care during a standard survey.</p> Signup and view all the answers

What does FSES stand for?

<p>Fire Safety Evaluation System</p> Signup and view all the answers

What is IDR?

<p>Informal Dispute Resolution</p> Signup and view all the answers

What does IJ represent?

<p>Immediate Jeopardy</p> Signup and view all the answers

What is the definition of Immediate Family?

<p>A husband or wife; natural or adoptive parent, child or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild.</p> Signup and view all the answers

What does Immediate Jeopardy refer to?

<p>A situation where the facility's noncompliance has likely caused serious harm or death to a resident.</p> Signup and view all the answers

What does LSC stand for?

<p>Life Safety Code</p> Signup and view all the answers

What does MAC represent?

<p>Medicare Area Contractor</p> Signup and view all the answers

What is Misappropriation of Resident Property?

<p>The deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without their consent.</p> Signup and view all the answers

What does NATCEP stand for?

<p>Nurse Aide Training and Competency Evaluation Program</p> Signup and view all the answers

What defines Neglect in a facility?

<p>Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.</p> Signup and view all the answers

What constitutes a New Admission?

<p>A resident admitted to the facility on or after the effective date of a denial of payment remedy.</p> Signup and view all the answers

What is Noncompliance?

<p>Any deficiency that causes a facility not to be in substantial compliance.</p> Signup and view all the answers

What does NOTC mean?

<p>No Opportunity to Correct</p> Signup and view all the answers

What does OTC stand for?

<p>Opportunity to Correct</p> Signup and view all the answers

What is a Partial Extended Survey?

<p>A survey evaluating additional participation requirements and verifying substandard quality of care.</p> Signup and view all the answers

What is Past Noncompliance (PNC)?

<p>A deficiency citation that meets specific criteria concerning compliance and evidence of correction.</p> Signup and view all the answers

What does Per Day CMP mean?

<p>A civil money penalty imposed for the number of days a facility is not in substantial compliance.</p> Signup and view all the answers

What is Per Instance CMP?

<p>A civil money penalty imposed for each instance of facility noncompliance.</p> Signup and view all the answers

What does QIES stand for?

<p>Quality Improvement and Evaluation System</p> Signup and view all the answers

Who is considered a Representative in the context of nursing facilities?

<p>Family members, legal guardians, friends, and ombudsmen assigned to the facility.</p> Signup and view all the answers

What is Self-Reported Noncompliance?

<p>Noncompliance reported by a facility to the State Survey Agency before it is identified by them.</p> Signup and view all the answers

What does SFF stand for?

<p>Special Focus Facility</p> Signup and view all the answers

What is the State Survey Agency (SA)?

<p>The entity responsible for conducting most surveys to certify compliance with CMS participation requirements.</p> Signup and view all the answers

What is the State Medicaid Agency (SMA)?

<p>The entity in the State responsible for administering the Medicaid program.</p> Signup and view all the answers

What does Substandard Quality of Care (SQC) mean?

<p>One or more deficiencies related to participation requirements that constitute immediate jeopardy to resident health or safety.</p> Signup and view all the answers

What is Substantial Compliance?

<p>A level of compliance such that any identified deficiencies pose no greater risk than minimal harm.</p> Signup and view all the answers

What describes a skilled nursing facility (SNF)?

<ol> <li>Is primarily engaged in providing skilled nursing care and related services; 2. Has a transfer agreement with participating hospitals.</li> </ol> Signup and view all the answers

What describes a nursing facility (NF)?

<ol> <li>Primarily engaged in providing skilled nursing care and related services; 2. Has a transfer agreement with participating hospitals.</li> </ol> Signup and view all the answers

What kinds of facilities may qualify as a SNF or NF?

<ol> <li>An entire facility for SNF or NF care; 2. A distinct part of a rehabilitation center; 3. A distinct part of a hospital; etc.</li> </ol> Signup and view all the answers

How many hours a day must SNFs provide licensed nursing services?

<p>24 hours a day</p> Signup and view all the answers

What are the RN coverage requirements for SNFs?

<p>For 8 consecutive hours a day, 7 days a week (more than 40 hours a week).</p> Signup and view all the answers

What are the requirements for a Director of Nursing (DON)?

<ol> <li>Must be a registered nurse; 2. Must be full-time.</li> </ol> Signup and view all the answers

What nursing requirements may be granted a waiver?

<ol> <li>24-hour licensed nursing requirement; 2. RN coverage 8 consecutive hours a day, 7 days a week requirement.</li> </ol> Signup and view all the answers

What is the maximum number of beds per resident room?

<p>4</p> Signup and view all the answers

What is the minimum space required for multi-patient rooms?

<p>80 sq ft per bed</p> Signup and view all the answers

What is the minimum space required for a private room?

<p>100 sq ft</p> Signup and view all the answers

What must be completed to certify a SNF or NF?

<ol> <li>A Life Safety Code (LSC) survey; 2. A standard survey.</li> </ol> Signup and view all the answers

When may state monitoring visits occur?

<ol> <li>During bankruptcy; 2. After a change of ownership; 3. After removal of Immediate Jeopardy.</li> </ol> Signup and view all the answers

Facilities must be subject to a standard survey no later than how long after the last day of the previous standard survey?

<p>15 months</p> Signup and view all the answers

The statewide average interval between standard surveys must not exceed what?

<p>12 months</p> Signup and view all the answers

What is the mandatory denial of payment for new admissions and termination time frame for the health portion of the standard survey?

<p>3 months</p> Signup and view all the answers

What is the mandatory denial of payment for new admissions and termination time frame for the life safety code portion of the standard survey?

<p>6 months</p> Signup and view all the answers

The State may conduct a standard or abbreviated survey within how many days of a change in ownership or management?

<p>60 days</p> Signup and view all the answers

What is the consequence of refusing to permit a survey team from performing an unannounced site visit?

<p>Withdrawal of a nurse aide training and competency evaluation program.</p> Signup and view all the answers

When are extended or partial extended surveys conducted?

<p>When substandard quality of care is identified.</p> Signup and view all the answers

What is the time frame for conducting an extended or partial extended survey after the standard survey?

<p>14 calendar days</p> Signup and view all the answers

Who must the State notify when substandard quality of care is identified?

<ol> <li>The State board responsible for the licensing of the nursing home administrator; 2. The attending physician of each resident identified.</li> </ol> Signup and view all the answers

Facilities may not use the IDR process to delay what?

<ol> <li>Scope and severity assessments of deficiencies; 2. Remedies imposed by the enforcing agency; etc.</li> </ol> Signup and view all the answers

What are the requirements for submitting a request for an IDR?

<ol> <li>Must be in writing; 2. Must be requested within the same 10 calendar day period for submitting a plan of correction.</li> </ol> Signup and view all the answers

How will the facility be notified of the availability of an IDR?

<p>It will be in the letter transmitting the official form CMS-2567.</p> Signup and view all the answers

If a facility is successful in disputing a deficiency during the IDR process, what will they receive?

<p>A revised 2567.</p> Signup and view all the answers

Any form CMS-2567 or plan of correction revised due to an IDR must be disclosed to whom?

<p>The Ombudsman.</p> Signup and view all the answers

When may an independent IDR be requested?

<p>When a civil money penalty is imposed and that penalty is subject to being collected and placed in escrow.</p> Signup and view all the answers

What is the time frame for an independent IDR following the notice of a civil money penalty?

<p>30 calendar days</p> Signup and view all the answers

Independent IDRs must be completed within how many days of a facility's request?

<p>60 calendar days</p> Signup and view all the answers

When may CMS collect and place imposed civil money penalties in an escrow account?

<p>Either the date on which the independent IDR process is completed or 90 calendar days after the notice of imposition.</p> Signup and view all the answers

A facility must request an independent IDR within how many days?

<p>10 calendar days of receipt of the offer.</p> Signup and view all the answers

What is another name for the form CMS-2567?

<p>Statement of Deficiencies.</p> Signup and view all the answers

For initial certification, when is the Medicare provider agreement effective?

<p>When the survey agency determines the facility is in substantial compliance.</p> Signup and view all the answers

When IJ exists, how quickly may termination and/or temporary management be imposed?

<p>In as few as 2 calendar days after the survey.</p> Signup and view all the answers

If the IJ is not removed, when will the provider agreement be terminated?

<p>No later than 23 days from the last day of the survey.</p> Signup and view all the answers

If IJ exists, what is the range of civil money penalty per day?

<p>$3,050 - $10,000 for each instance of deficiency.</p> Signup and view all the answers

If IJ exists, remedies may be imposed within how many days from the notice?

<p>2 calendar days (one of which must be a working day).</p> Signup and view all the answers

If IJ exists, what must facilities submit to verify removal?

<p>An allegation that the IJ has been removed with sufficient detail.</p> Signup and view all the answers

What will happen if a facility is still in noncompliance 6 months after the survey that determined noncompliance?

<p>CMS or the State will terminate the Medicare and/or Medicaid provider agreements.</p> Signup and view all the answers

Termination of Medicare and/or Medicaid provider agreements may be imposed within how many days from the date the facility receives notice?

<p>15 calendar days</p> Signup and view all the answers

If a facility is in noncompliance, when will denial of payment for new admissions be imposed if substantial compliance is not achieved?

<p>No later than 30 days after the last day of the survey.</p> Signup and view all the answers

Study Notes

Nursing Home Reform Regulations

  • Three key expectations: substantial compliance with Medicare/Medicaid requirements and state law, prompt addressing of deficiencies, and provision of necessary care for residents’ optimal functioning.

Survey Types

  • Abbreviated Standard Survey: Gathers resident-centered data on facility compliance based on complaints or changes in management.
  • Expanded Survey: Conducted when substandard care is suspected, expanding scope beyond standard surveys.

Definitions and Compliance

  • Abuse: Willful infliction of harm, confinement, or intimidation resulting in pain or mental anguish.
  • Deficiency: Failure of a facility to meet participation requirements set by Social Security Act or federal regulations.
  • Substantial Compliance: Identified deficiencies pose minimal risk to resident health or safety.

Standard and Certification Processes

  • Certification of Compliance: Facility meets compliance and can participate in Medicaid/Medicare.
  • Certification of Noncompliance: Facility fails to comply and cannot participate in Medicaid/Medicare.
  • Dually Participating Facility: A facility with provider agreements in both Medicare and Medicaid.

Enforcement Actions

  • Remedies include civil money penalties, termination of provider agreements, and denial of new admissions.
  • No Opportunity to Correct (NOTC): Remedies imposed immediately upon noncompliance determination.
  • Opportunity to Correct (OTC): Facility allowed to rectify deficiencies before penalties are imposed.

Resident Safety and Monitoring

  • Immediate Jeopardy (IJ): Noncompliance that poses serious risk to resident health or safety, necessitating urgent action.
  • Facilities subject to standard survey within 15 months; average interval between surveys not to exceed 12 months.

Special Programs and Training

  • NATCEP: Nurse Aide Training and Competency Evaluation Program ensuring adequate staff training.
  • Directed In-Service Training: Required when deficiencies are identified to improve care quality.

Financial Penalties

  • Civil money penalties can vary per day or per instance of noncompliance.
  • When IJ exists, CMS may impose daily penalties ranging from $3,050 to $10,000.

Investigative Processes

  • Informal Dispute Resolution (IDR): A process allowing facilities to contest deficiencies, must be requested in writing within specified timeframe post-survey.
  • Civil monetary penalties can be held in escrow during independent IDR proceedings.

Facility Requirements

  • Skilled nursing facilities (SNFs) must provide 24-hour licensed nursing services.
  • Minimum space requirements: private rooms must be 100 sq ft, multi-patient rooms must be 80 sq ft per bed, maximum of 4 beds per room.

Administrator and Staffing

  • Directors of Nursing (DON) must be registered nurses and work full-time.
  • Waivers for staffing requirements may be granted under specific conditions.

Compliance Consequences

  • Facilities failing to address deficiencies within 6 months face termination of Medicare/Medicaid agreements.
  • New admissions cannot occur if a facility is under denial of payment for noncompliance.

Additional Notes

  • Facilities must inform the ombudsman of any IDR process changes post-revision.
  • State monitoring visits ensure compliance and resident welfare, particularly during changes in ownership or after serious incidents.

Knowledge Gaps and Education

  • Knowledge gaps arise from deficiencies in practice standards, staff competencies, or minimum participation requirements.
  • Education is considered a viable solution to address noncompliance issues.

Direct Plan of Correction

  • Developed by the State or CMS, or a temporary manager.
  • Outlines specific actions to rectify noncompliance and address underlying root causes.

Temporary Management

  • Involves CMS or State appointing a temporary manager with broad authority.
  • Responsibilities include staff management, financial obligations, and procedural alterations to fix operational deficiencies.

Denial of Payment for New Admissions

  • Mandatory denial imposed when a facility remains noncompliant after three months post-survey or has shown substandard care on the last three consecutive surveys.

CMS Authority

  • CMS holds the power to deny payments for Medicare and/or Medicaid residents.

Factors for Denial of Payment for All Residents

  • Determined by seriousness of survey findings, facility's noncompliance history, and effectiveness of previously attempted remedies.

State Monitoring

  • Involves oversight of deficiency correction by a state monitor to prevent resident harm.
  • Implemented when harm occurs or is potentially likely.

State Ban on Admissions

  • CMS can enforce bans for Medicare/Medicaid residents; states can impose bans on private pay residents.

CMS-2567 Timeline

  • Form must be to the facility by the 10th working day after the survey ends.

Plan of Correction Submission

  • Facilities are required to submit correction plans by the 10th calendar day after receiving CMS-2567.

Requirements for an Acceptable Plan of Correction

  • Must detail actions to address affected residents, identify potential impacts on others, outline measures to prevent recurrence, include monitoring plans, and specify completion dates for corrective actions.

Onsite Revisit Criteria

  • Mandatory onsite revisit required if initial surveys or follow-ups reveal substandard care or immediate jeopardy.

Remedies Imposition

  • Remedies can be applied at any time for any level of noncompliance.

Onsite Revisit Flexibility

  • Surveys can be conducted any time as a response to any level of noncompliance.

Notice of Isolated Deficiencies

  • Facilities receiving isolated deficiencies without actual harm will receive Form A, indicating minimal potential harm.

Plan of Correction Exemption

  • No correction plan required for receiving a Notice of Isolated Deficiencies Which Cause No Actual Harm With the Potential for Minimal Harm (Form A).

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Test your knowledge with these flashcards based on the CMS State Operations Manual. This quiz covers key expectations and processes related to nursing home reforms and regulations. Perfect for nursing students and professionals looking to reinforce their understanding of compliance requirements.

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