State Operations Manual 
Chapter 7 - Survey and Enforcement Process for Skilled 
Nursing Facilities and Nursing Facilities 
 
(Rev. 213, 02-10-23) 
 
Table of Contents 
 
Transmittals for Chapter 7 
 
7000 - Introduction 
7001 - Definitions and Acronyms 
7002 - Change in Certification Status for Medicaid Nursing Facilities 
7004 - Skilled Nursing Facility - Citations and Description 
7004.1 - Citations 
7004.2 - Description of Skilled Nursing Facility 
7006 - Nursing Facility - Citations and Description 
7006.1 - Citations 
7006.2 - Description of Nursing Facility 
7008 - Types of Facilities That May Qualify as Skilled Nursing Facilities and Nursing 
Facilities 
7010 - Skilled Nursing Facilities Providing Outpatient Physical Therapy, Speech 
Pathology, or Occupational Services 
7012 - Reserved 
7014 - Special Waivers Applicable to Skilled Nursing Facilities and Nursing Facilities 
7014.1 - Waiver of Nurse Staffing Requirements 
7014.1.1 - Waiver of 7-Day Registered Nurse (RN) Requirement for 
Skilled Nursing Facilities 
7014.1.2 - Waivers of Nurse Staffing Requirements in Nursing Facilities 
7014.1.3 - Waivers of Nurse Staffing Requirements for Dually 
Participating Facilities 
7014.1.4 - Initial Requests for Nurse Waiver 
7014.2 - Waiver of Life Safety Code 
7014.3 - Variations of Patient Room Size and/or Beds Per Room 
7014.4 - Documentation to Support Waivers or Variations 
 
Survey Process 
 
7200 -Emphasis, Components, and Applicability  7201 - Survey Team Size and Composition - Length of Survey 
7201.1 - Survey Team Size 
7201.2 - Team Composition 
7201.3 - Length of Survey 
7202 - Conflicts of Interest for Federal and State Employees 
7202.1 - Introduction 
7202.2 - Conflicts of Interest 
7202.2.1 - Prima Facie Conflicts of Interest 
7202.2.2 - Examples of Potential Conflicts of Interest 
7202.3 - Report and Investigation of Improper Acts 
7203 - Survey Protocol 
7203.1 - Introduction 
7203.2 - Initial Certification Surveys 
7203.3 - Resurvey of Participating Facilities 
7203.4 - Post Survey Revisit (Follow-Up) 
7203.5 - Abbreviated Standard Survey 
7203.6 - Extended Survey/Partial Extended Survey 
7203.7 -State Monitoring Visits 
7205 - Survey Frequency:  15-Month Survey Interval and 12-Month State-wide Average 
7205.1 - Last Day of Survey  
7205.2 - Scheduling and Conducting Surveys 
7205.3 - Determining Standard Survey Interval for Each Facility 
7205.4 - Assessing Compliance with Survey Frequency Requirements 
7205.5 - Actions to Ensure Compliance with Standard Survey Interval 
7207 - Unannounced Surveys 
7207.1 - Introduction 
7207.2 - All Surveys Must Be Unannounced 
7207.2.1 - Nonsequential Order 
7207.2.2 - Variance in Timing (Time of Day, Day of Week, Time of 
Month) 
7207.3 - CMS Review of State Scheduling Procedures 
7207.4 - Imposition of Civil Money Penalties 
7207.5 - Withdrawal of Nurse Aide Training and Competency Evaluation 
Program or Competency Evaluation Program When Entity Providing the Program 
Refuses to Permit Unannounced State Visit 
7210 - Substandard Quality of Care and Extended and Partial Extended Surveys 
7210.1 - Introduction 
7210.2 - Expansion of the Survey 
7210.5 - Time Frames  7210.6 - Notices 
7210.7 - Nurse Aide Training and Competency Evaluation Program and 
Competency Evaluation Program 
7212 - Informal Dispute Resolution 
7212.1 - Introduction 
7212.2 - Purpose 
7212.3 - Mandatory Elements of Informal Dispute Resolution 
7212.4 - Additional Elements for Federal Informal Dispute Resolution 
7213 - Independent Informal Dispute Resolution 
7213.1 - Introduction 
7213.2 - Purpose 
7213.3 - Independent Informal Dispute Resolution Requirements 
7213.4 - Applicability of the Independent Informal Dispute Resolution Process 
7213.5 - Key Elements of the Independent Informal Dispute Resolution 
7213.6 - Qualifications of an Independent Informal Dispute Resolution Entity or 
Person(s) 
7213.7 - Approval of an Independent Informal Dispute Resolution Process 
7213.8 - State Budget and Payment for Expenses 
7213.9 - Independent Informal Dispute Resolution Recommendation and Final 
Decision 
7213.10 - Additional Elements for Federal Independent Informal Dispute 
Resolution Process 
7300 - Certification of Compliance and Noncompliance for Skilled Nursing Facilities and 
Nursing Facilities 
7300.1 - Introduction 
7300.2 - Survey and Certification Responsibility 
7300.3 - Initial Survey and Certification Responsibility 
7300.4 - Effect of CMSs Validation Authority 
7301 - Action When Facility Is Not in Substantial Compliance 
7301.1 - Immediate Jeopardy Exists 
7301.2 - Immediate Jeopardy Does Not Exist 
7301.3 - Prospective Providers 
7303 - Appeal of Certification of Noncompliance 
7304 - Mandatory Immediate Imposition of Federal Remedies 
7304.1 - Criteria for Mandatory Immediate Imposition of Federal Remedies Prior 
to the Facilitys Correction of Deficiencies 
7304.2 - Effective Dates for Immediate Imposition of Federal Remedies 
7304.3 - Responsibilities of the State Survey Agency and the CMS Location 
when there is an Immediate Imposition of Federal Remedies  
7305 - Notice Requirements 
7305.1 - Initial Notices by Surveying Entity  7305.1.1  When No Immediate Jeopardy Exists and an Opportunity to 
Correct Will be Provided Before Remedies Are Imposed 
7305.1.2  When No Immediate Jeopardy Exists and No Opportunity to 
Correct Will be Provided Before Remedies Are Imposed 
7305.1.3  When Immediate Jeopardy Exists 
7305.2 - CMS Location, State Medicaid Agency, and State Formal Notices When 
Remedies are Imposed  
7305.2.1 - Who Sends the Formal Notice of Remedies 
7305.2.2 - Contents of the Formal Notice of Remedies 
7305.2.3 - Required Time Periods for Formal Notice 
7305.2.4 - Nurse Aide Training and Competency Evaluation 
Program/Competency Evaluation Program 
7305.3 - Overlap of Notice of Remedies 
7305.4 - Means of Sending Notice 
7307 - Immediate Jeopardy Exists 
7307.1 - Statutory and Regulatory Basis 
7307.2 - Purpose 
7308 - Enforcement Actions When Immediate Jeopardy (IJ) Exists 
7309 - Key Dates When Immediate Jeopardy (IJ) Exists  
7309.1 - 2nd Calendar Day 
7309.2 - 5th-21st Calendar Day  
7309.3 - No Later Than 10th Business Day  
7309.4 - By 23rd Calendar Day  
7310 - Immediate Jeopardy(IJ) Does Not Exist 
7312 - Considerations Affecting Enforcement Recommendation to Impose Remedies 
When Immediate Jeopardy Does Not Exist 
7313 - Procedures for Recommending Enforcement Remedies When Immediate Jeopardy 
(IJ) Does Not Exist 
7313.1 - Facilities Given an Opportunity to Correct Deficiencies prior to the 
Immediate Imposition of Federal Remedies  
7314 - Special Procedures for Recommending and Providing Notice of Imposition and 
Rescission of Category 1 Remedies and Denial of Payment for New Admissions 
Remedy 
7315 - Disagreements About Remedies When Immediate Jeopardy Does Not Exist 
7316 - Key Dates When Immediate Jeopardy Does Not Exist 
7316.1 - Required Actions When There Is an Opportunity to Correct 
7316.2 - Required Actions When There Is No Opportunity to Correct 
7317 - Acceptable Plan of Correction 
7317.1 - Verifying Facility Compliance 
7317.2 - Revisits  7317.3 - Noncompliance Cycles 
7319 - Procedures for Certifying Compliance 
7319.1 - Non-State Operated Skilled Nursing Facilities and Nursing Facilities or 
Dually Participating Facilities 
7319.2 - State-Operated Facilities 
7320 - Action When There is Substandard Quality of Care 
7320.1 - Repeated Substandard Quality of Care 
7320.1.1 - Action to Be Taken When a Facility Is Found to Have Provided 
Substandard Quality of Care on Last Three Standard Surveys 
7320.1.2 - Factors Which May or May Not Affect a Determination of 
Repeated Substandard Quality of Care 
7320.1.3 - Notification Requirements 
7321 - Skilled Nursing Facility or Dually Participating Facility Readmission to Medicare 
or Medicaid Program After Termination (Excludes Medicaid-only Nursing 
Facilities) 
7321.1 - Readmission Criteria 
7321.2 - Reasonable Assurance Concept 
7321.3 - Reasonable Assurance Surveys 
7321.3.1 - First Visit 
7321.3.2 - Second Visit 
7321.4 - Effective Date of Provider Agreement 
 
Enforcement Process 
 
7400 - Enforcement Remedies for Skilled Nursing Facilities (SNFs), Nursing 
Facilities (NFs) and Dually Participating Facilities (SNFs/NFs) 
7400.1 - Available Federal Enforcement Remedies  
7400.2 - -Enforcement Remedies for the State Medicaid Agency 
7400.3 - Selection of Remedies  
7400.3.1 - Matrix for Scope & Severity  
7400.4 - Other Factors That May Be Considered in Selecting Enforcement Remedy 
Within a Remedy Category 
7400.6 - When To Select Remedy From Specific Remedy Category 
7400.6.1 - Category 1 
7400.6.2 - Category 2 
7400.6.3 - Selection from Category 3 
7410 - Life Safety Code Enforcement Guidelines for Skilled Nursing Facilities and 
Nursing Facilities 
7410.1 - Application of the Enforcement Regulations to Life Safety Code Surveys 
Conducted in Skilled Nursing Facilities and Nursing Facilities  7410.2 - Life Safety Code Scope and Severity Determination 
7410.2.1 - Scope Levels 
7410.2.2 - Severity Levels 
7410.3 - Survey Coordination and Data Entry 
7410.4 - Guidance on Enforcement Remedies 
7410.5 - Imposition of Remedies 
7410.6 - Life Safety Code Survey Waiver Guidance 
7410.6.1 - Temporary Waiver 
7410.6.2 - Continuing Waivers 
7410.6.3 - Enforcement and Waived Life Safety Code Requirements 
 
Remedies 
 
7500 - Directed Plan of Correction 
7500.1 - Introduction 
7500.2 - Purpose 
7500.3 - Elements of a Directed Plan of Correction 
7500.4 - Causes 
7500.5 - Notice of Imposition of Directed Plan of Correction 
7502 - Directed In-Service Training 
7502.1 - Introduction 
7502.2 - Purpose 
7502.3 - Appropriate Resources for Directed In-Service Training Programs 
7502.4 - Further Responsibilities 
7502.5 - Notice of Imposition of Directed In-Service Training 
7504 - State Monitoring 
7504.1 - Introduction 
7504.2 - Purpose 
7504.3 - Qualifications 
7504.4 - When to Impose the State Monitoring Remedy 
7504.5 - Frequency 
7504.6 - Duration 
7506 - Denial of Payment for all New Medicare and Medicaid Admissions for Skilled 
Nursing Facilities and Nursing Facilities 
7506.1 - Introduction 
7506.2 - Optional Denial of Payment for All New Admissions Remedy 
7506.3 - Mandatory Denial of Payment for All New Admissions Remedy 
7506.4 - Duration and Resumption of Payments  7506.5 - Effect of Remedy on Status of Residents Admitted, Discharged, or on 
Temporary Leave and Readmitted Before, On, or After the Effective Date of the 
Denial of Payment for New Admissions Remedy 
7508 - Secretarial Authority to Deny All Payment for All Medicare and Medicaid 
Residents 
7508.1 - Introduction 
7508.2 - Duration and Resumption of Payments 
 
Civil Money Penalties 
 
7510 - Basis for Imposing Civil Money Penalties 
7510.1  Determining Citations of Past Noncompliance at the Time of the Current 
Survey 
7510.2  Documentation of Past Noncompliance Citations on the CMS-2567 
7510.3  Applicability to Disapproval of Nurse Aide Training and Competency 
Evaluation Program 
7512 - Compliance With Section 1128A of the Social Security Act 
7514 - Special Procedures Regarding Compliance Decision and Overlap of Remedies 
7516 - Determining Amount of Civil Money Penalty 
7516.1 - Range of Penalty Amounts 
7516.2 - Factors Affecting Amount of Penalty 
7516.3 - Changing Amount of Civil Money Penalty 
7516.4 - Reduction of a Civil Money Penalty by 50 Percent for Self-Reporting 
and Prompt Correction of Noncompliance 
7518 - Effective Date of Civil Money Penalty 
7520 - Notice of Imposition of Civil Money Penalty 
7520.1 - Responsibility for Issuing Notice 
7520.2 - Content of Notice 
7522 - Duration of Civil Money Penalty 
7522.1 - Revisit Identifies New Noncompliance and Same Data Tag is Selected 
7522.2 - Revisit Identifies New Noncompliance and a Different Data Tag is 
Selected 
7522.3 - Noncompliance - Immediate Jeopardy Does Not Exist 
7522.4 - Noncompliance - Immediate Jeopardy Exists 
7524 - Settlement of Civil Money Penalty 
7526 - Appeal of Noncompliance That Led to Imposition of Civil Money Penalty 
7526.1 - Facility Requests Hearing on Noncompliance That Led to Imposition of 
Civil Money Penalty 
7526.2 - Facility Waiver of Right to Hearing 
7528 - When Penalty Is Due and Payable  7528.1 - When a Civil Money Penalty Subject to Being Collected and Placed in 
an Escrow Account is Imposed 
7528.2 - After Final Administrative Decision 
7528.3 - No Hearing Requested 
7528.4 - After Request to Waive Hearing 
7528.5 - After Substantial Compliance Is Achieved 
7528.6 - After Effective Date of Termination 
7530 - Notice of Amount Due and Collectible 
7530.1 - Contents of Notice 
7530.2 - Method of Payment 
7534 - Disposition of Collected Civil Money Penalty 
7534.1 - Collected From Medicare or Dually-Participating Facility 
7534.2 - Collected From Medicaid Facility 
7534.2.1 - Entities Other Than Nursing Homes May Receive Collected 
Civil Money Penalty Funds From the State 
7534.3 - Collected From Dually Participating Facility 
7534.4 - Collected Amounts from a Dually-Participating Facility or Medicare 
Facility and Held in Escrow 
7535  Uses of Civil Money Penalty Funds 
7536 - Loss of Nurse Aide Training and Competency Evaluation Program or Competency 
Evaluation Program as a Result of Civil Money Penalty 
7536.1 - Definition of Assessed 
7536.2 - Effective Date for Prohibition of Nurse Aide Training and Competency 
Evaluation Program or Competency Evaluation Program When Civil Money 
Penalty of $5,000 or More Is Assessed 
7550 - Temporary Management 
7550.1 - Introduction 
7550.2 - Purpose 
7550.3 - Authority of Temporary Manager 
7550.4 - Selection of Temporary Manager 
7550.5 - Conditions of Temporary Management 
7550.6 - Orienting and Supervising Temporary Manager 
7550.7 - Notice of Imposition of Temporary Management 
7550.8 - Duration 
7550.9 - Alternatives to Temporary Management 
7552 - Transfer of Residents and Transfer of Residents with Closure of Facility 
7552.1 - Introduction 
7552.2 - Responsibility for Transferring Residents 
7552.3 - States Prerogative to Close Facility and Transfer Residents  7556 - Termination Procedures for Skilled Nursing Facilities and Nursing Facilities 
When Facility Is Not in Substantial Compliance With Participation Requirements 
7556.1 - Introduction 
7556.2 - When There Is Immediate Jeopardy 
7556.3 - When There Is No Immediate Jeopardy 
7600 - Continuation of Payments During Correction 
7600.1 - Introduction 
7600.2 - Purpose 
7600.3 - Criteria for Continued Payment During Correction Period 
7600.4 - Approval of Plan and Timetable for Corrective Action 
7600.5 - Facility Takes Corrective Action According to Its Approved Plan of 
Correction and Has Achieved Substantial Compliance 
7600.6 - Facility Does Not Take Corrective Action According to Its Approved 
Plan of Correction and Has Not Achieved Substantial Compliance 
7600.7 - Facility Takes Corrective Action According to its Plan of Correction But 
Fails to Achieve Substantial Compliance 
7600.8 - Facility Does Not Take Corrective Action According to Its Plan of 
Correction and Has Achieved Substantial Compliance 
7600.9 - When State Opts for Alternative Remedies in Lieu of Termination and 
Criteria Are Not Met 
7700 - Nurse Aide Registry and Findings of Abuse, Neglect, or Misappropriation of 
Property 
7700.1- Notification Procedures- Preliminary Determinations 
7700.2 - Conduct of Hearing for Nurse Aides 
7700.3- Reporting Findings 
7701 - Reporting Abuse to Law Enforcement and the Medicaid Fraud Control Unit 
 
Program Management 
 
7800 - Consistency of Survey Results 
7800.1 - Introduction 
7800.2 - Measuring Consistency 
7801 - Sanctions for Inadequate State Survey Performance 
7803 - Educational Programs 
7803.1 - Introduction 
7803.2 - Purpose 
7803.3 - Methodology 
7803.4 - Suggested Training Modalities 
7805 - Criteria for Reviewing State Plan Amendments for Specified and Alternative 
Enforcement Remedies  7805.1 - Introduction 
7805.2 - Specified Remedies 
7805.3 - Alternative Remedies 
7805.4 - Additional Remedies 
7807 - State/Federal Disagreements About Timing and Choice of Remedies 
7807.1 - Introduction 
7807.2 - Disagreement About Whether Facility Has Met Requirements 
7807.3 - Disagreement About Decision to Terminate 
7807.4 - Disagreement About Timing of Facility Termination 
7807.5 - Disagreement About Remedies 
7807.6 - One Enforcement Decision 
7809 - Nurse Aide Training and Competency Evaluation Program and Competency 
Evaluation Program Disapprovals 
7809.1 - Introduction 
7809.2 - Applicability to Past Noncompliance 
7809.3 - Waiver of Program Disapproval 
7809.4 - Notice 
7809.5 - Change of Ownership 
7809.6 - Ability to Appeal a Finding of Substandard Quality of Care that Resulted 
in the Disapproval of a Nurse Aide Training and Competency Evaluation Program 
7809.7  Effective Date of Disapproval of Nurse Aide Training and Competency 
Evaluation Program or Competency Evaluation Program 
 
Disclosure 
 
7900 - Information Disclosed to Public 
7901 - Requesting Public Information 
7902 - Charges for Information 
7903 - Time Periods for Disclosing Skilled Nursing Facility/Nursing Facility Information 
7903.1 - Information That Must Be Disclosed Within 14 Days of Request 
7903.2 - Disclosure Time frames 
7904 - Information Furnished to States Long Term Care Ombudsman 
7904.1 -Information Given to Long Term Care Ombudsman 
7904.2 - Federal Surveys 
7905 - Information Furnished to State by Facility with Substandard Quality of Care 
7905.1 - Information Provided to the State Survey Agency by Facility 
7905.2 - Failure to Provide Information Timely 
7905.3 - Federal Surveys 
7906 - Information Furnished to Attending Physician and State Board  7906.1 - State Notification of Noncompliance 
7906.2 - Federal Surveys 
7907 - Access to Information by State Medicaid Fraud Control Unit 
  7000 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Chapter 7 implements the nursing home survey, certification, and enforcement 
regulations at 42 CFR Part 488.  No provisions contained in this chapter are intended to 
create any rights or remedies not otherwise provided in law or regulation. 
 
The nursing home reform regulation establishes several expectations.  The first is that 
providers remain in substantial compliance with Medicare/Medicaid program 
requirements as well as State law.  The regulation emphasizes the need for continued, 
rather than cyclical compliance.  The enforcement process mandates that policies and 
procedures be established to remedy deficient practices and to ensure that correction is 
lasting; specifically, that facilities take the initiative and responsibility for continuously 
monitoring their own performance to sustain compliance.  Measures such as the 
requirements for an acceptable plan of correction emphasize the ability to achieve and 
maintain compliance leading to improved quality of care.  (See 7304.4 for plan of 
correction requirements.) 
 
The second expectation is that all deficiencies will be addressed promptly.  The standard 
for program participation mandated by the regulation is substantial compliance.  The 
State and the Centers for Medicare and Medicaid Services (CMS) Location will take 
steps to bring about compliance quickly.   In accordance with 7304, remedies such as 
civil money penalties, temporary managers, directed plans of correction, in-service 
training, denial of payment for new admissions, and State monitoring can be imposed 
before a facility has an opportunity to correct its deficiencies. 
 
The third expectation is that residents will receive the care and services they need to meet 
their highest practicable level of functioning.  The process detailed in these sections 
provides incentives for the continued compliance needed to enable residents to reach 
these goals.  
 
It should be noted that references to the State would be applicable, as appropriate, to the 
CMS Location throughout this chapter when the CMS Location is the surveying entity.  It 
should also be noted that in cases where the State is authorized by CMS and/or the State 
Medicaid Agency, the State may provide notice of imposition of certain remedies on their 
behalf, within applicable notice requirements.  
 
It should be noted that failure of CMS or the State to act timely does not invalidate 
otherwise legitimate survey and enforcement determinations. 
 
The ASPEN Enforcement Manager (AEM) is the data system used by CMS and all States 
for data entry and reporting on nursing home survey and enforcement activities. 
    7001 - Definitions and Acronyms 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Abbreviated Standard Survey means a survey other than a standard survey that gathers 
information primarily through resident-centered techniques on facility compliance with 
the requirements for participation.  An abbreviated standard survey may be premised on 
complaints received; a change in ownership, management, or director of nursing; or other 
indicators of specific concern.  (42 CFR 488.301) 
 
Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or 
punishment with resulting physical harm, pain, or mental anguish.  (42 CFR 488.301) 
 
ACO - Automated Survey Processing Environment (ASPEN) Central Office. 
 
Act - the Social Security Act 
 
AEM - Automated Survey Processing Environment (ASPEN) Enforcement Manager. 
 
ASPEN - Automated Survey Processing Environment. 
 
CASPER - Certification and Survey Provider Enhanced Reporting. 
 
Certification of Compliance means that 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. 
 
Certification of Noncompliance means that 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. 
 
CFR - Code of Federal Regulations. 
 
CMP - civil money penalty. 
 
CMPTS - Civil Money Penalty Tracking System. 
 
CMS - Centers for Medicare & Medicaid Services (formerly HCFA). 
 
Deficiency means a skilled nursing facilitys or nursing facilitys failure to meet a 
participation requirement specified in the Act or in 42 CFR Part 483 Subpart B.  (42 CFR 
488.301) 
 
DoPNA or DPNA - denial of payment for new admissions. 
 
DPoC - directed plan of correction. 
  Dually Participating Facility means a facility that has a provider agreement in both the 
Medicare and Medicaid programs. 
 
Educational programs means programs that include any subject pertaining to the long-
term care participation requirements, the survey process, or the enforcement process. 
 
Enforcement action means the process of imposing one or more of the following 
remedies: termination of a provider agreement; denial of participation; denial of payment 
for new admissions; denial of payment for all residents; temporary manager; civil money 
penalty; State monitoring; directed plan of correction; directed in-service training; 
transfer of residents; closure of the facility and transfer of residents; or other CMS-
approved alternative State remedies.  
 
Expanded survey means an increase beyond the core tasks of a standard survey. A 
standard survey may be expanded at the surveying entitys discretion.  When surveyors 
suspect substandard quality of care they should expand the survey to determine if 
substandard quality of care does exist. 
 
Extended survey means a survey that evaluates additional participation requirements 
subsequent to finding substandard quality of care during a standard survey.  (42 CFR 
488.301) 
 
Facility means a skilled nursing facility or nursing facility, or a distinct part of a skilled 
nursing facility or nursing facility, in accordance with 42 CFR 483.5.  (42 CFR 488.301)   
(See 7008 for entities that qualify as skilled nursing facilities and nursing facilities.) 
 
FSES  Fire Safety Evaluation System. 
 
IDR  informal dispute resolution. 
 
IJ  immediate jeopardy. 
 
Immediate family means 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.  (42 CFR 
488.301.) 
 
Immediate jeopardy means a situation in which the facilitys noncompliance with one 
or more requirements of participation has caused, or is likely to cause, serious injury, 
harm, impairment, or death to a resident.  (42 CFR 488.301) 
 
Independent IDR  Independent informal dispute resolution 
 
LSC  Life Safety Code. 
 
MAC means Medicare Area Contractor.   
Misappropriation of resident property means the deliberate misplacement, 
exploitation, or wrongful, temporary or permanent use of a residents belongings or 
money without the residents consent.  (42 CFR 488.301) 
 
NATCEP  Nurse Aide Training and Competency Evaluation Program. 
 
Neglect means failure to provide goods and services necessary to avoid physical harm, 
mental anguish, or mental illness.  (42 CFR 488.301) 
 
New admission, for purposes of a denial of payment remedy, means a resident who is 
admitted to the facility on or after the effective date of a denial of payment remedy and, if 
previously admitted, has been discharged before that effective date.  (See 7506 for 
examples of what does and does not constitute a new admission for purposes of the 
remedy.)  (42 CFR 488.401) 
NF  nursing facility. 
 
Noncompliance means any deficiency that causes a facility not to be in substantial 
compliance.  (42 CFR 488.301) 
 
No Opportunity to Correct means the facility will have remedies imposed immediately 
after a determination of noncompliance has been made. 
 
NOTC  no opportunity to correct. 
 
Nurse aide means any individual providing nursing or nursing-related services to 
residents in accordance with 42 CFR 483.75(e)(1).  (CFR 42 488.301) 
 
Nursing facility means a Medicaid nursing facility.  (42 CFR 488.301) 
 
OBRA 87 - the Omnibus Budget Reconciliation Act of 1987. 
 
Opportunity to Correct means the facility is allowed an opportunity to correct identified 
deficiencies before remedies are imposed. 
 
OTC  opportunity to correct. 
 
Partial extended survey means a survey that evaluates additional participation 
requirements and verifies the existence of substandard quality of care during an 
abbreviated standard survey.  (42 CFR 488.301.) 
 
Past Noncompliance means a deficiency citation at a specific survey data tag (F-tag or 
K-tag), that meets all of the following three criteria: 
 
1)  The facility was not in compliance with the specific regulatory requirement(s) (as 
referenced by the specific F-tag or K-tag) at the time the situation occurred;   
2)  The noncompliance occurred after the exit date of the last standard 
(recertification) survey and before the survey (standard, complaint, or revisit) 
currently being conducted, and 
 
3)  There is sufficient evidence that the facility corrected the noncompliance and is in 
substantial compliance at the time of the current survey for the specific regulatory 
requirement(s), as referenced by the specific F-tag or K-tag. 
 
Per day civil money penalty means a civil money penalty imposed for the number of 
days a facility is not in substantial compliance. 
 
Per instance civil money penalty means a civil money penalty imposed for each 
instance of facility noncompliance. 
 
PNC  past noncompliance. 
 
PoC - plan of correction.  (42 CFR 488.401) 
 
QIES - Quality Improvement and Evaluation System. 
 
Representative-for purposes of educational programs, means family members, legal 
guardians, friends, and ombudsmen assigned to the facility; for purposes of Independent 
IDR, means either the residents legal representative or the individual filing a complaint 
involving or on behalf of a resident. 
 
Self-Reported Noncompliance- Noncompliance that is reported by a facility to the State 
Survey Agency before it is identified by the State, CMS, or reported to the State or CMS 
by an entity other than the facility itself.  
 
SFF  Special Focus Facility. 
 
Skilled nursing facility means a Medicare-certified nursing facility that has a Medicare 
provider agreement.  (42 CFR 488.301) 
 
SMA  State Medicaid Agency. 
 
SNF  skilled nursing facility. 
 
SQC  substandard quality of care. 
 
Standard survey means a periodic, resident-centered inspection that gathers information 
about the quality of service furnished in a facility to determine compliance with the 
requirements of participation.  (42 CFR 488.301) 
  State survey agency (SA) means the entity responsible for conducting most surveys to 
certify compliance with the Centers for Medicare and Medicaid Services participation 
requirements. 
 
State Medicaid Agency means the entity in the State responsible for administering the 
Medicaid program. 
 
Substandard quality of care  means one or more deficiencies related to participation 
requirements under 42 CFR 483.13, resident behavior and facility practices, 
42 CFR 483.15, quality of life, or 42 CFR 483.25, quality of care, that constitute either 
immediate jeopardy to resident health or safety (level J, K, or L); a pattern of or 
widespread actual harm that is not immediate jeopardy (level H or I); or a widespread 
potential for more than minimal harm, but less than immediate jeopardy, with no actual 
harm (level F).  (42 CFR 488.301) 
 
Substantial compliance means a level of compliance with the requirements of 
participation such that any identified deficiencies pose no greater risk to resident health 
or safety than the potential for causing minimal harm.  Substantial compliance constitutes 
compliance with participation requirements.  (42 CFR 488.301) 
 
7002 - Change in Certification Status for Medicaid Nursing Facilities  
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When Medicaid nursing facilities wish to participate as Medicare skilled nursing 
facilities, the State does not necessarily need to conduct a new survey.  The State submits 
the information obtained during the most recent Medicaid survey and other 
documentation required for an initial certification of a skilled nursing facility to the CMS 
Location.   The CMS Location will consider guidance in 2777D and 2778 of this 
manual in making a determination about whether a new survey should be conducted.  
(Also see 1819(g) and 1919(g) of the Act, and 42 CFR 488.308 for authority to 
conduct surveys anytime there is a question about compliance.) 
 
7004 - Skilled Nursing Facility - Citations and Description 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7004.1 - Citations 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A skilled nursing facility is defined in 1819(a) of the Act and 42 CFR 488.301. 
 
7004.2 - Description of Skilled Nursing Facility 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A skilled nursing facility is a facility which: 
    Is primarily engaged in providing to residents skilled nursing care and related 
services for residents who require medical or nursing care; or  
 
  Is primarily engaged in providing to residents skilled rehabilitation services for 
the rehabilitation of injured, disabled, or sick persons and is not primarily for 
the care and treatment of mental diseases;  
 
  Has in effect a transfer agreement (meeting the requirements of 1861(1) of the 
Act with one or more hospitals having agreements in effect under 1866 of the 
Act); and 
 
  Meets the requirements for a skilled nursing facility described in subsections (b), 
(c), and (d) of 1819 of the Act. 
 
A skilled nursing facility provides a level of care distinguishable both from the level of 
intensive care furnished by a general hospital and from the level of custodial or 
supportive care furnished by nursing homes primarily designed to provide daily services 
above room and board.  This level of care is reflected in the participation requirements 
for skilled nursing facilities.  While the requirements call for a wide range of specialized 
medical services and the employment by the facility of a variety of paramedical and 
skilled nursing personnel, the emphasis on restorative services is oriented toward 
providing services for residents who require and can benefit from skilled nursing and one 
or more types of skilled restorative services, e.g., physical or speech therapy. 
 
7006 - Nursing Facility - Citations and Description 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7006.1 - Citations 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A nursing facility is defined in 1919(a) of the Act and 42 CFR 488.301. 
 
7006.2 - Description of Nursing Facility 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A nursing facility is a facility that: 
 
  Is primarily engaged in providing residents with skilled nursing care and related 
services for residents who require medical or nursing care; rehabilitation services 
for the rehabilitation of injured, disabled, or sick persons; or on a regular basis, 
health-related care and services to individuals who because of their mental or 
physical condition require care and services (above the level of room and board) 
which is available to them only through these facilities, and is not primarily for 
the care and treatment of mental diseases; 
    Has in effect a transfer agreement (meeting the requirements of 1861(l) of the 
Act) with one or more hospitals having agreements in effect under 1866 of the 
Act; and 
 
  Meets the above requirements and subsections (b), (c), and (d) of 1919 of the 
Act. 
 
7008 - Types of Facilities That May Qualify as Skilled Nursing Facilities 
and Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A Skilled Nursing Facility or Nursing Facility may be: 
 
  An entire facility for skilled nursing facility or nursing facility care; 
 
  A distinct part of a rehabilitation center; 
 
  A distinct part of a hospital, such as a wing or a section;  
 
  A distinct part of a skilled nursing facility or nursing facility (see 2762.B of this 
manual); or 
 
  A religious nonmedical health care institution operated or listed and certified by 
the First Church of Christ, Scientist, Boston, Massachusetts. 
 
An institution that is primarily for the care and treatment of mental diseases cannot be a 
skilled nursing facility or nursing facility. 
 
7010 - Skilled Nursing Facilities Providing Outpatient Physical 
Therapy, Speech Pathology, or Occupational Services 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A skilled nursing facility may provide Part B outpatient physical therapy, speech therapy, 
or occupational therapy services either directly or under arrangement. 
 
7012 - Reserved 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7014 - Special Waivers Applicable to Skilled Nursing Facilities and 
Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7014.1 - Waiver of Nurse Staffing Requirements 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
  7014.1.1 - Waiver of 7-Day Registered Nurse (RN) Requirement for 
Skilled Nursing Facilities 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The requirements for long-term care facilities require that a skilled nursing facility 
provide 24-hour licensed nursing services, an RN for 8 consecutive hours a day, 7 days a 
week (more than 40 hours a week), and that there be an RN designated as Director of 
Nursing on a full time basis.  The CMS Location, acting on behalf of the Secretary, may 
waive the requirement in the following circumstances: 
 
  The facility is located in a rural area and the supply of skilled nursing facility 
services is not sufficient to meet area needs; 
 
  The facility has one full-time registered nurse regularly on duty 40 hours a week.  
This may be the same individual or part-time individuals.  This nurse may or may 
not be the Director of Nursing and may perform some Director of Nursing and 
some clinical duties if the facility so desires; and either;  
 
  The facility has residents whose physicians have indicated, through admission 
notes or physicians orders, that the residents do not need RN or physician care 
for a 48 hour period; or 
 
  A physician or RN will spend the necessary time at the facility to provide the care 
that residents need during the days that an RN is not on duty.  This requirement 
refers to clinical care of the residents who need skilled nursing services. 
 
If a waiver is granted, the CMS Location, acting on behalf of the Secretary, must provide 
notice of the waiver to the State long-term care ombudsman and to the State protection 
and advocacy system for the mentally ill and intellectually disabled.  The facility granted 
such a waiver must notify residents of the facility (or responsible guardians) and 
members of their immediate families of the waiver. 
 
A waiver of the RN requirement is subject to annual renewal by the Secretary. 
 
7014.1.2 - Waivers of Nurse Staffing Requirements in Nursing Facilities 
(Rev. 97, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) 
 
The requirements for long-term care facilities also require that nursing facilities provide 
24-hour licensed nursing, provide an RN for 8 consecutive hours a day, 7 days a week, 
and that there be an RN designated as Director of Nursing on a full-time basis.  The State 
may waive these requirements if the following conditions are met: 
 
  The facility demonstrates to the satisfaction of the State that it has made diligent 
efforts to recruit the appropriate personnel and is unable to do so; 
    The State determines that a waiver will not endanger the health or safety of the 
residents in the facility; and 
 
  The State finds that an RN or physician is obligated to respond immediately to 
phone calls from the facility for periods when licensed nursing services are not 
available. 
 
The State may grant a waiver from the 24-hour licensed nursing requirement; the 8 
consecutive hours a day, 7 days a week requirement, or both.  A facility may be waived 
from the requirement to designate a Director of Nursing if it has been waived from either 
the requirement to provide 24-hour licensed nursing services or the 8 consecutive hours a 
day, 7 days a week requirement. 
 
If a waiver is granted, the State must provide notice of the waiver to the State long-term 
care ombudsman and to the State protection and advocacy system for the mentally ill and 
intellectually disabled. The facility granted the waiver must notify residents of the facility 
(or responsible guardians) and members of their immediate families of the waiver. 
 
7014.1.3 - Waivers of Nurse Staffing Requirements for Dually 
Participating Facilities 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If a facility dually participates in both the Medicare and Medicaid programs, it is subject 
to the waiver criteria for skilled nursing facilities.  Therefore, a skilled nursing 
facility/nursing facility may only have the 8 consecutive hours a day, 7 days a week 
requirement waived.  In this case, the waiver is granted by the CMS Location. 
 
7014.1.4 - Initial Requests for Nurse Waiver 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The first time that a nursing facility applies for a waiver, the State conducts an onsite 
survey before it may grant a waiver.  The purpose of the survey is to establish that the 
waiver will not endanger the health and safety of residents.  A full survey is not required. 
However, the survey must be of sufficient scope to ensure that the granting of the waiver 
will not endanger the health and safety of the residents. 
 
While the acuity of illness of skilled nursing facility level residents makes an onsite visit 
desirable to confirm that the facility actually meets the requirements for a nurse staffing 
waiver, it is not required.  The waiver determination may be made based on 
documentation of these requirements submitted by the skilled nursing facility. 
 
7014.2 - Waiver of Life Safety Code  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(See 2472 and 7410.) 
  7014.3 - Variations of Patient Room Size and/or Beds Per Room 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Resident rooms may have no more than four beds per room and must afford a minimum 
of 80 square feet per bed in multi-patient rooms.  Single rooms must measure at least 100 
square feet.  42 CFR 483.70(d)(3) states that variations may be permitted in individual 
cases where the facility demonstrates in writing that the variations are in accordance with 
the special needs of the residents and will not adversely affect their health and safety.  A 
variation is construed to mean a waiver.  The CMS Location has jurisdiction to approve 
such waivers or variances.  The State has jurisdiction to approve them in Medicaid-only 
cases.  
 
7014.4 - Documentation to Support Waivers or Variations 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The State should place an asterisk to the left of the data tag item on the Statement of 
Deficiencies and Plan of Correction, Form CMS-2567, and include the required 
documentation to support the recommendation with the certification packet.  The State 
enters a W in the plan of correction field in the certification tab in ASPEN for the 
waived requirement. 
    Survey Process 
 
7200 -Emphasis, Components, and Applicability 
(Rev. 97, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) 
 
Skilled nursing facilities and nursing facilities must be in compliance with the 
requirements in 42 CFR Part 483, Subpart B to receive payment under Medicare or 
Medicaid.  To certify a skilled nursing facility or nursing facility, complete at least: 
 
  A life safety code survey; and 
 
  A standard survey (Forms CMS-670, 671, 672, 677, 801 through 807, and 
Exhibits 85, 86, 88 to 95). 
 
Follow the procedures in Appendix P of this manual for conducting all surveys of skilled 
nursing facilities and nursing facilities, whether freestanding, distinct parts, or dually 
participating.  Do not use these procedures for surveys of intermediate care facilities for 
individuals with intellectual disabilities (ICFs/IID), swing-bed hospitals, or skilled 
nursing sections of hospitals that are not separately certified as skilled nursing facility 
distinct parts. 
 
7201 - Survey Team Size and Composition - Length of Survey 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7201.1 - Survey Team Size 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Survey team size will vary, depending primarily on the size of the facility being 
surveyed.  The State (or, for Federal teams, the CMS Location) determines how many 
members will be on the team.  Survey team size is normally based upon the following 
factors: 
 
  The bed size of the facility to be surveyed; 
 
  Whether the facility has a historical pattern of serious deficiencies or complaints; 
 
  Whether the facility has special care units; and 
 
  Whether new surveyors are to accompany a team as part of their training. 
 
7201.2 - Team Composition 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
  The State (or, for Federal teams, the CMS Location) decides what the composition of the 
survey team will be, as long as certain statutory and regulatory requirements are met.  
Sections 1819(g)(2)(E) and 1919(g)(2)(E) of the Act and 42 CFR 488.314 require that: 
 
  Skilled nursing facility and nursing facility standard surveys be conducted by a 
multidisciplinary team of professionals, at least one of whom must be a registered 
nurse; 
 
  Surveyors be free of conflicts of interest (see 7202); and 
 
  Surveyors successfully complete a training and testing program in survey and 
certification techniques that has been approved by the Secretary.  In other words, 
surveyors must successfully complete the CMS-approved training and pass the 
Surveyor Minimum Qualifications Test.  (See 4009.1 of this manual for 
additional information concerning Surveyor Minimum Qualifications Test 
requirements.)  
 
Within these parameters, the States (or, for Federal teams, the CMS Location) are free to 
choose the composition of each team, and it is the State that determines what constitutes a 
professional.  However, CMS offers the following guidance: 
 
  The State or CMS Location should consider using more than one registered nurse 
on teams that will be surveying a facility known to have a large proportion of 
residents with complex nursing or restorative needs. 
 
  Because of the strong emphasis on resident rights, the psychosocial model of care, 
and rehabilitative aspects of care in the regulations and the survey process, the 
team should include social workers, registered dietitians, pharmacists, activity 
professionals, or rehabilitation specialists, when possible. 
 
  It is important, to the extent practical, to utilize team members with clinical 
expertise and knowledge of current best practices that correspond to the resident 
populations assessed needs, the services rendered in the facility to be surveyed, 
and the type of facility to be surveyed.  For example, if the facility has a known 
problem in dietary areas, there should be an effort to include a dietitian on the 
team; if a known problem in quality of life, a social worker.  If the facility 
specializes in the care of residents with post trauma head injuries and strokes, a 
physical therapist may be included on the team. 
 
  In addition to members of individual disciplines routinely included as members of 
the survey team, consideration should be given to the use of individuals in 
specialized disciplines who may not routinely participate as team members.  
These individuals would be available to assist the survey team when specific 
problems or questions arise.  Consultants in these suggested disciplines include, 
but are not limited to, physicians, physician assistants, nurse practitioners,  physical, speech, and occupational therapists, dieticians, sanitarians, engineers, 
licensed practical nurses, social workers, pharmacists, and gerontologists. 
 
  In order to comply with the requirement that No individual shall serve as a 
member of a ... team (surveying a SNF or NF) unless the individual has 
successfully completed (the CMS-approved) training and testing program, 
surveyors in training, i.e., those who have not successfully completed the required 
training, must be accompanied on-site by a surveyor who has successfully 
completed the required training and testing.  While it is desirable that all survey 
team members be fully qualified, CMS recognizes that trainees must be given 
opportunities to perform survey functions so that they can achieve fully 
qualified status.  Participation in actual surveys is a valuable and integral part of 
a training program.  In fact, in the orientation program designed for newly 
employed surveyors, CMS recommends that 3 weeks be spent in the field as part 
of the training. 
 
7201.3 - Length of Survey 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The length of a standard survey in terms of person hours is expected to vary, based on the 
size and layout of the facility and the number and complexity of concerns that need to be 
investigated onsite. 
 
7202 - Conflicts of Interest for Federal and State Employees  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7202.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Conflicts of interest may arise within the Medicare/Medicaid certification when public 
employees duties give them the potential for private gain (monetary or otherwise) or the 
opportunity to secure unfair advantages for outside associates.  The same should be 
required of State employees whose positions may produce possible conflicts of interest. 
This includes all State surveyors and their supervisors.  There are a number of Federal 
and State laws setting forth criminal penalties for abuses of privileged information, 
abuses of influence, and other abuses of public trust. 
 
Federal employees are required to make a declaration of any outside interests and to 
update it whenever such interests are acquired.  The same should be required of State 
employees whose positions may produce possible conflicts of interest.  Both CMS and 
the State are responsible for evaluating the need for preventive measures to protect the 
integrity of the certification program.  When certification work is performed by agencies 
other than CMS or the State, the State administrators and the subagency administrators 
have a shared responsibility for this surveillance.  
  In the case of States, it is not necessary to inform CMS of all potential conflict situations.  
However, if an overt abuse requires corrective action, the CMS Location must be 
informed as described in 7202. 
 
7202.2 - Conflicts of Interest 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7202.2.1 - Prima Facie Conflicts of Interest 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Under 42 CFR 488.314(a)(4), any of the following circumstances disqualifies a surveyor 
for surveying a particular skilled nursing facility or nursing facility: 
 
a.  The surveyor currently works, or, within the past 2 years, has worked as an 
employee, as employment agency staff at the facility, or as an officer, consultant, 
or agent for the facility to be surveyed; 
 
b.  The surveyor has any financial interest or any ownership interest in the facility.  
(Indirect ownership, such as through a broad based mutual fund, does not 
constitute financial or ownership interest for purposes of this restriction.); 
 
c.  The surveyor has an immediate family member who has a relationship with a 
facility described in 7202.  An immediate family member is defined in 
42 CFR 488.301; or 
 
d.  The surveyor has an immediate family member who is a resident in the facility. 
 
7202.2.2 - Examples of Potential Conflicts of Interest 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
CMS and the States must consider all relevant circumstances that may exist beyond the 
benchmarks given in 7202 to ensure that the integrity of the survey process is preserved.  
For example, a surveyor may not have worked for the facility to be surveyed for more 
than 2 years, but may have left the facility under unpleasant circumstances, or, may not 
currently have an immediate family member who resides there, but may have recently 
had one residing there who the surveyor considers to have received inadequate care. 
 
The following are typical of situations that may raise a question of possible conflicts of 
interest for Federal or State employees of an agency representing the Medicare/Medicaid 
survey and certification program.  However, they do not necessarily constitute conflicts 
of interest. 
 
a.  Participation in ownership of a health facility located within the employing State; 
 
b.  Service as a director or trustee of a health facility; 
  c.  Service on a utilization review committee; 
 
d.  Private acceptance of fees or payments from a health facility or group of health 
facilities or association of health facility officers for personal appearances, 
personal services, consultant services, contract services, referral services, or for 
furnishing supplies to a health facility; 
 
e.  Participation in a news service disseminating trade information to a segment of 
the health industry; and 
 
f.  Having members of ones immediate family engaged in any of the above 
activities. 
 
7202.3 - Report and Investigation of Improper Acts 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Any acts of employees in violation of Federal or State laws or regulations regarding 
conflicts of interest should be handled in accordance with applicable Federal or State 
procedures.  In the case of State employees, conflicts of interest violations must be 
reported to the CMS Location , and the CMS Location must be kept advised of the 
corrective actions.  States should ask for assistance or advice in the case of any 
impropriety involving a conflict of interest that cannot be handled immediately under an 
applicable State procedure.  The regional office of the Inspector General, along with the 
CMS Location, will then work in close cooperation with the responsible State officials 
until the matter is resolved.  
 
7203 - Survey Protocol 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7203.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This protocol is established pursuant to 1819(g)(2)(C) and 1919(g)(2)(C) of the Act to 
provide guidance to surveyors conducting surveys of long-term care facilities 
participating in the Medicare and Medicaid programs.  The protocol consists of survey 
procedures, worksheets, and interpretive guidelines.  It serves to explain and clarify the 
requirements for long-term care facilities and all surveyors measuring facility compliance 
with Federal requirements are required to use it.  The purpose of this protocol is to 
provide suggestions, interpretations, check lists, and other tools for use both in 
preparation for the survey and when performing the survey onsite. 
 
The interpretive guidelines merely define or explain the relevant statutes and regulations 
and do not impose any additional costs or place other burdens on any health care facility.  
(See 2712 of this manual.) 
 
  7203.2 - Initial Certification Surveys  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(See also 2005 and 7300 of this manual.) 
 
All initial surveys must verify substantial compliance with the regulatory requirements 
contained in 42 CFR 483.5 through 42 CFR 483.75.  Follow Appendix P, Survey 
Protocol for Long Term Care Facilities. 
 
If distinct part status is at issue, determine whether the facility meets the criteria for 
certification as a distinct part.  (See 2762.B of this manual.) 
 
7203.3 - Resurvey of Participating Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Follow the procedures specified in Appendix P of this manual for standard and extended 
surveys. 
 
7203.4 - Post Survey Revisit (Follow-Up) 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
When the State has cited deficiencies during the course of a survey, the survey agency 
may, as necessary, conduct a post survey revisit to determine if the facility now meets the 
requirements for participation.  (See also 7317.) 
 
7203.5 - Abbreviated Standard Survey 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(See also Appendix P, VII of this manual.) 
 
This survey focuses on particular tasks that relate, for example, to complaints received, or 
a change of ownership, management, or Director of Nursing.  It does not cover all the 
aspects covered in the standard survey, but rather concentrates on a particular area of 
concern(s).  The survey team (or surveyor) may investigate any area of concern and make 
a compliance decision regarding any regulatory requirement, whether or not it is related 
to the original purpose of the survey complaint. 
 
1 - Complaint Investigations 
 
If the States review of a complaint allegation(s) concludes that one or more violations of 
requirements may have occurred, and only a survey can determine whether a 
deficiency(ies) exist, conduct a standard or abbreviated standard survey.  (See Chapter 5 
and Appendix P of this manual.) 
 
2 - Substantial Changes in a Facilitys Organization and Management 
  If a facility notifies you of a change in organization or management, review the change to 
ensure compliance with the regulations.  Request copies of the appropriate documents, 
e.g., written policies and procedures, personnel qualifications and agreements, etc., if 
they were not submitted.  If changes in a facilitys organization and management are 
significant and raise questions of its continued substantial compliance, determine, 
through a survey, whether deficiencies have resulted.  Collect information about changes 
in the facilitys organization and management on the Medicare and other Federal Care 
Program General Enrollment, Form CMS-855. 
 
7203.6 - Extended Survey/Partial Extended Survey 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If, as a result of its findings during the standard survey or abbreviated standard survey, 
the team suspects substandard quality of care as defined in 42 CFR 488.301, it expands 
the survey.  If the expanded survey verifies substandard quality of care, the State or CMS 
Location conducts an extended survey or a partial extended survey in accordance with 
procedures in Appendix P of this manual.  (See 7210.2 and Appendix P of this manual.) 
 
7203.7 -State Monitoring Visits 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
State monitoring visits are visits by the State to oversee a providers compliance status 
and are not done as part of the State monitoring remedy.  Some CMS Locations and 
States call these State monitoring visits monitoring visits.  For example, these visits 
may occur: 
 
  During bankruptcy, in those cases in which CMS has authorized such visits. 
 
  After a change of ownership, as authorized by the CMS Location; 
 
  During or shortly after removal of immediate jeopardy when the purpose of the 
visit is to ensure the welfare of the residents by providing an oversight presence, 
rather than to perform a structured follow-up visit; and 
 
  In other circumstances, as authorized by the CMS Location. 
 
When a State monitoring visit results in a Federal deficiency, the State will identify the 
survey in ASPEN as complaint and create an intake and survey record in ACTS.  (See 
Chapter 5 of this manual for additional instructions.) 
 
 
 
 
 
   
7205 - Survey Frequency:  15-Month Survey Interval and 12-Month 
State-wide Average 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
This section does not apply to the date of survey for remedy imposition and termination 
timeframes.  The survey and certification provisions set forth in 1819(g)(2)(A)(iii) and 
1919(g)(2)(A)(iii) of the Act and in 42 CFR 488.308 require that each skilled nursing 
facility and nursing facility be subject to a standard survey no later than 15 months after 
the last day of the previous standard survey and that the statewide average interval 
between standard surveys of skilled nursing facilities and nursing facilities not exceed 12 
months.  This date is entered in L34 on the form CMS-1539. 
 
 
7205.1 - Last Day of Survey 
 (Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
The last day of survey is the last day of onsite observations during a survey, regardless of 
whether the exit conference was performed on that same day. 
 
For purposes of computing three months or six months from a finding of noncompliance 
when the health and life safety code portions of the survey are on the same enforcement 
track, use the last day of onsite observations of the standard health survey on which the 
noncompliance was identified, regardless of which survey preceded the other.  Even 
when the life safety code was the second of the two surveys to be performed on the same 
enforcement track, and it was the survey that found the noncompliance, the clock still 
starts on the last day of the standard health survey and will always be used to begin 
counting the number of noncompliance days.  For purposes of the first notice of 
noncompliance, use the last day of the survey that found the cited noncompliance.  
 
When two separate enforcement tracks are being used (one track for the health portion 
and one track for the life safety code portion of the standard survey), the mandatory 
denial of payment for new admissions and termination time frames would be three 
months and six months, respectively, for each separate portion. 
 
7205.1.1- Setting the Mandatory 3-Month and 6-Month Sanction Time 
Frames 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
These dates should be set based on full months rather than on a number of days.  With 
few exceptions, these dates should be set by simply going to the same numerical date in 
the 3rd or 6th month following the survey date.  For example, if a survey ended on 
January 15, the 3-month effective date for the mandatory denial of payment for new 
admissions remedy is April 15, and the 6-month mandatory termination date is July 15. 
  Exceptions to this rule involve those cases for which a 3-month or 6-month numerical 
date is not on the calendar.  In these cases, move ahead a day or two to the beginning of 
the next month.  For example, if a survey ended on January 31, the 3-month effective 
date for the mandatory denial of payment for new admissions remedy would be April 31.  
However, since there is no April 31, the 3-month effective date is May 1 and the 6-month 
mandatory termination date is July 31. 
 
7205.2 - Scheduling and Conducting Surveys 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The State must complete a standard survey of each skilled nursing facility and nursing 
facility not later than 15 months after the previous standard survey.  
 
Facilities with excellent histories of compliance may be surveyed less frequently to 
determine compliance, but no less frequently than every 15 months and the State-wide 
standard survey average must not exceed 12 months. 
 
1 - Changes That May Prompt Survey 
 
If the State is concerned that a change of ownership, management firm, administrator, or 
Director of Nursing may have caused a decline in the quality of care or services furnished 
by a skilled nursing facility or nursing facility, it may conduct a standard or abbreviated 
standard survey within 60 days of the change. 
 
Facilities with poor histories of compliance may be surveyed more frequently to ensure 
that residents are receiving quality care in a safe environment. 
 
2 - Frequency 
 
The State may conduct surveys as frequently as necessary to determine if a facility 
complies with the participation requirements as well as to determine if the facility has 
corrected any previously cited deficiencies.  There is no required minimum time which 
must elapse between surveys. 
 
3 - Conducting Complaint Surveys 
 
Refer to complaint investigation procedures in Chapter 5 and Appendix P of this manual.  
 
7205.3 - Determining Standard Survey Interval for Each Facility 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The standard survey interval for each facility (which may not exceed 15 months) is 
calculated as follows: 
    The number of days between the completion of the current and last standard 
survey is divided by 31 to determine the number of months between standard 
surveys for each provider; 
 
  The last day of the entire health and life safety code survey is the date used to 
calculate the interval. 
 
  If an extended survey is conducted as a result of the health portion of a standard 
survey, the last day of the health portion of the standard survey is used to 
calculate the survey frequency requirements, if the health portion occurs after the 
life safety code portion.  The date of the extended survey is not used in 
calculating the survey interval or state-wide average requirements;  
 
  Abbreviated standard surveys are not counted in the calculation.  An abbreviated 
standard survey is a survey other than a standard survey to gather information on 
facility compliance with the requirements for participation primarily through 
resident-centered techniques.  An abbreviated standard survey may be premised 
on complaints received; a change of ownership, management, or Director of 
Nursing; or other indicators of specific concern.  (See 42 CFR 488.301.); 
 
  When an abbreviated standard survey is changed to a standard survey, the                   
standard survey is counted in the calculation of the standard survey interval using 
the last date of the entire health and life safety code survey as the survey date; and 
 
  Revisits are not counted in the calculation of the standard survey interval. 
 
The Certification and Survey Provider Enhanced Reporting system (CASPER) is used to 
identify facilities that have not received a standard survey within 15 months. 
 
Survey information for the fiscal year must be entered by November 15 of each year in 
order for CMS Headquarters to calculate the state-wide average. 
 
7205.4 - Assessing Compliance with Survey Frequency Requirements 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The state-wide average interval for each State is available through the Certification and 
Survey Provider Enhanced Reporting system (CASPER). 
 
The CMS Location has ongoing responsibility to monitor a States compliance with the 
survey frequency requirements. 
 
7205.5 - Actions to Ensure Compliance with Standard Survey Interval 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
No action is necessary if the standard survey interval for a provider is not greater than 15 
months and the state-wide average is not greater than 12 months.   
If the standard survey interval for a provider is greater than 15 months and/or the state-
wide average interval is greater than 12 months, the CMS Location will notify the State, 
determine if a problem exists, and take appropriate action.  This action is specified in 
Chapter 8 of this manual. 
 
7207 - Unannounced Surveys  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(Also see 2700 and Chapter 5 of this manual.) 
 
7207.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This instruction implements 1819(g)(2)(A) and 1919(g)(2)(A) of the Act, and 
42 CFR 488.307.  It also reiterates CMS policy that all nursing home surveys are to be 
unannounced, including standard surveys, complaint surveys and onsite revisit surveys.   
 
7207.2 - All Surveys Must Be Unannounced 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The State has the responsibility for keeping surveys unannounced and their timing 
unpredictable.  This gives the State agency doing the surveying greater ability to obtain 
valid information because it increases the probability that the surveys will observe 
conditions and care practices that are typically present.  While the Act and implementing 
regulations referenced in 7207.1 require that standard surveys be unannounced, it is 
CMS intention and expectation to not announce any type of nursing home survey such 
as abbreviated, onsite revisit, or complaint surveys.  Therefore, if CMS conducts standard 
surveys or validation surveys, the CMS Location must follow the same procedures as 
required of the States to not announce surveys.  The only exceptions to this policy would 
be if, for instance, some additional documentation was required and the most efficient 
way to obtain it would be through making an appointment and revisiting the facility or 
asking that it be provided via electronic means.  The State should notify the State 
ombudsmans office according to the protocol developed between the State and the State 
ombudsmans office.  This protocol must ensure strict confidentiality concerning the 
survey dates.  (See Appendix P of this manual.)  
 
To increase the opportunity for unpredictability in standard surveys, the State survey 
agencies and Federal surveyors should incorporate the following procedures when 
planning facility surveying: 
 
7207.2.1 - Nonsequential Order 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Facilities, within a given geographical area, should not be surveyed in the same order as 
was conducted in the previous standard survey;   
7207.2.2 - Variance in Timing (Time of Day, Day of Week, Time of 
Month) 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
(See also Appendix P and Appendix PP of this manual) 
 
When facilities are surveyed, the time of day, day of the week, and time of month should 
be varied from the time of the previous standard survey.  The time of day that surveyors 
begin should extend beyond the business hours of 8:00 a.m. to 6:00 p.m.  In addition, the 
day of the week should vary to include weekend days, Saturday, and Sunday.  At least 10 
percent of standard health surveys must begin either on the weekend or in the 
evening/early morning hours before 8:00 a.m. or after 6:00 p.m.  Likewise, the month in 
which a survey begins should not, if possible, coincide with the month in which the 
previous standard survey was conducted.  For example, unannounced standard health 
surveys could begin at: 
 
  7:30 p.m. on a Monday evening in early July (previous standard survey occurred 
early June); 
 
  6:00 a.m. on a Wednesday morning and survey continues through the weekend 
until it is completed; or 
 
  11:00 a.m. on a Saturday morning. 
 
In addition, standard health surveys that are conducted to satisfy the 10 percent 
requirement must be conducted on consecutive days.  Consecutive days mean calendar 
days and are to include Saturdays, Sundays, and Holidays.  For example, beginning a 
survey at 8:00 a.m. on a Saturday morning must be continued until its completion through 
the weekend and into the following week.  Since survey time on holidays is reported as 
weekend time, surveys initiated on holidays can be counted toward the 10 percent off-
hour survey requirement.  Holidays are defined as those days that are recognized by the 
State as a State or Federal holiday. 
 
Since the off-hour survey requirement is to reduce the predictability of when a survey 
will occur, States must begin some off-hour surveys in each of these targeted time 
frames, i.e., early morning, evening, and holidays/weekend. 
 
NOTE:  If there are situations that arise and the State determines that a standard 
survey cannot be conducted on consecutive days, the State must contact 
the CMS Location and obtain approval prior to the commencement of the 
standard survey or within reasonable time after the initial start day. 
 
7207.3 - CMS Review of State Scheduling Procedures 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
  The CMS Location reviews annually each of its States procedures for assuring that 
nursing home surveys are not announced through the methods by which they are 
scheduled or conducted. 
 
7207.4 - Imposition of Civil Money Penalties 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If any individual has, in any way, given prior notification to a facility of the date of a 
standard survey, the State or CMS is to contact the regional Office of the Inspector 
General and report the name of the individual and what has occurred.  The Office of the 
Inspector General will further investigate and make a determination as to whether or not a 
Federal civil money penalty will be imposed.  A civil money penalty of up to $2,000 may 
be imposed under 1819(g)(2)(A)(I) and 1919(g)(2)(A)(I) of the Act.  The provisions of 
1128A of the Act apply to civil money penalties.  The imposition of a civil money 
penalty applies only when a standard survey is announced.  See 42 CFR Part 1005 for 
policy developed by the Office of the Inspector General regarding administrative appeals 
of Federal civil money penalties. 
 
7207.5 - Withdrawal of Nurse Aide Training and Competency 
Evaluation Program or Competency Evaluation Program When Entity 
Providing the Program Refuses to Permit Unannounced State Visit 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Regulations at 42 CFR 483.151(e)(3) require the State to withdraw approval of a nurse 
aide training and competency evaluation program or a nurse aide competency evaluation 
program when the entity providing the program refuses to permit an unannounced visit 
by the State. 
 
7210 - Substandard Quality of Care and Extended and Partial Extended 
Surveys 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(See also Appendix P, III of this manual.) 
 
7210.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This section is established pursuant to 1819(g)(2)(B) and 1919(g)(2)(B) of the Act and 
42 CFR 488.310 to provide guidance to surveyors in conducting an extended or partial 
extended survey.  The only time an extended or partial extended survey is conducted is 
when substandard quality of care is identified.  This section also explains notice 
requirements as required in 1819(g)(5)(C) and 1919(g)(5)(C) of the Act and 
42 CFR 488.325, disclosure of results of surveys and activities, when substandard quality 
of care is found.  This section discusses the consequences to a nurse aide training and 
competency evaluation program and competency evaluation program when an extended  or partial extended survey is conducted.  (See 7001 for the definition of substandard 
quality of care.) 
 
7210.2 - Expansion of the Survey 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When the State or CMS Location conducts a standard survey or abbreviated standard 
survey and suspects substandard quality of care but does not have sufficient information 
to confirm or refute the substandard quality of care, the survey may be expanded.  (See 
Appendix P and 7210 of this manual.)  This expansion of the standard or abbreviated 
standard survey does not necessarily constitute an extended or partial extended survey. 
 
If the expanded survey does not verify substandard quality of care but finds 
noncompliance, the State or CMS Location prepares Form CMS-2567 and follows the 
procedures required in 7305. 
 
If the expanded survey verifies substandard quality of care, the State or CMS Location 
conducts an extended survey or a partial extended survey in accordance with procedures 
in Appendix P of this manual. 
 
7210.5 - Time frames 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
An extended or partial extended survey should be conducted immediately after the 
standard or abbreviated standard survey, but, if delayed, not later than 14 calendar days 
after completion of a standard survey or abbreviated standard survey which found that the 
facility had furnished substandard quality of care. 
 
7210.6 - Notices 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
When substandard quality of care is identified as a result of a standard or abbreviated 
standard survey, an extended or partial extended survey is conducted.  In addition to the 
notices required of all surveys in 7300, the State must issue notices to the following: 
 
  The State board responsible for the licensing of the nursing home administrator; 
and  
 
  The attending physician of each resident who was identified as having been 
subject to substandard quality of care.  (See 7320.) 
 
According to 42 CFR 488.325, disclosure of results of surveys and activities, the facility 
is responsible for submitting to the State the names of the attending physician for each 
resident who was identified as having been subject to substandard quality of care, 
regardless of whether payment is made through Medicare, Medicaid, or private pay.  (See 
7905.)   
7210.7 - Nurse Aide Training and Competency Evaluation Program and 
Competency Evaluation Program 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
As required in 1819(f)(2)(B)(iii)(I)(b) and 1919(f)(2)(B)(iii)(I)(b) of the Act, the nurse 
aide training and competency evaluation program and competency evaluation program 
must be denied or withdrawn when an extended or partial extended survey is conducted.  
(Also see 7809.) 
 
7212 - Informal Dispute Resolution 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
7212.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Regulations at 42 CFR 488.331 require that CMS and the States, as appropriate, offer 
skilled nursing facilities, nursing facilities, and dually participating facilities an informal 
opportunity to dispute cited deficiencies upon the facilitys receipt of the official Form 
CMS-2567.  A State does not need to create any new or additional processes if its 
existing process meets the requirements described in 7212.3.  The informal dispute 
resolution process, as established by the State or CMS Location, must be in writing so 
that it is available for review upon request. 
 
7212.2 - Purpose  To Provide Facilities an Opportunity To Informally 
Dispute Cited Deficiencies After a Survey 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
7212.3 - Mandatory Elements of Informal Dispute Resolution 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
The following elements must be included in each informal dispute resolution process 
offered: 
 
1.  Upon their receipt of the official Form CMS-2567, facilities must be offered an 
informal opportunity, to dispute deficiencies with the entity that conducted the 
survey. 
 
2.  Facilities may not use the informal dispute resolution process to delay the formal 
imposition of remedies or to challenge any other aspect of the survey process, 
including the: 
 
  Scope and severity assessments of deficiencies with the exception of scope 
and severity assessments that constitute substandard quality of care or 
immediate jeopardy;   
  Remedy(ies) imposed by the enforcing agency; 
 
  Alleged failure of the survey team to comply with a requirement of the 
survey process; 
 
  Alleged inconsistency of the survey team in citing deficiencies among 
facilities; 
 
  Alleged inadequacy or inaccuracy of the informal dispute resolution 
process. 
 
3.  Facilities must be notified of the availability of informal dispute resolution in the 
letter transmitting the official Form CMS-2567.  (See Exhibit 139 in this manual 
for transmission of Form CMS-2567.)  Notification of this process should inform 
the facility: 
 
  That it may request the opportunity for informal dispute resolution, and 
that if it requests the opportunity, the request must be submitted in writing 
along with an explanation of the specific deficiencies that are being 
disputed.  The request must be made within the same 10 calendar day 
period the facility has for submitting an acceptable plan of correction to 
the surveying entity;  
 
  Of the name, address, and telephone number of the person the facility 
must contact to request informal dispute resolution; 
 
  How informal dispute resolution may be accomplished in that State, e.g., 
by telephone, in writing, or in a face-to-face meeting. 
 
  Of the name and/or the position title of the person who will be conducting 
the informal dispute resolution, if known. 
 
States should be aware that CMS holds them accountable for the legitimacy of the 
informal dispute resolution process including the accuracy and reliability of conclusions 
that are drawn with respect to survey findings.  This means that while States may have 
the option to involve outside persons or entities they believe to be qualified to participate 
in this process, it is the States, not outside individuals or entities that are responsible for 
informal dispute resolution decisions.  So, when an outside entity conducts the informal 
dispute resolution process, the results may serve only as a recommendation of 
noncompliance or compliance to the State.  The State will then make the final informal 
dispute resolution decision and notify the facility of that decision.  CMS will look to the 
States to assure the viability of these decision- making processes, and holds States 
accountable for them. 
  Since CMS has ultimate oversight responsibility relative to a States performance, it may 
be appropriate for CMS to examine specific informal dispute resolution decisions or the 
overall informal dispute resolution process to determine whether a State is arriving at a 
correct result.  For dually participating or Medicare-only facilities, informal dispute 
findings are in the manner of recommendations to CMS and, if CMS has reason to 
disagree with those findings, it may reject the conclusions from informal dispute 
resolution and make its own binding determinations of noncompliance. 
 
4.  Failure to complete informal dispute resolution timely will not delay the effective 
date of any enforcement action against the facility. 
 
5.  When a facility is unsuccessful during the process at demonstrating that a 
deficiency should not have been cited, the surveying entity must notify the facility 
in writing that it was unsuccessful. 
 
6.  When a facility is successful during the informal dispute resolution process at 
demonstrating that a deficiency should not have been cited: 
 
  On the CMS Form-2567, annotate deficiency (ies) citations as deleted 
and/or change deficiency (ies) citation findings, as recommended. A State 
survey agency manager or supervisor will sign and date the revised CMS 
Form-2567. 
 
  Adjust the scope and severity assessment for deficiencies, if warranted and in 
accordance with CMS policy. 
 
  The State survey agency will promptly recommend to CMS that any 
enforcement action(s) imposed solely because of deleted or altered deficiency 
citations be reviewed, changed or rescinded. 
 
The facility has the option to request a clean (new) copy of the Form CMS-2567.  
However, the clean copy will be the releasable copy only when a clean (new) plan of 
correction is both provided and signed by the facility.  The original Form CMS-2567 is 
disclosable when a clean plan of correction is not submitted and signed by the facility.  
Any Form CMS-2567 and/or plan of correction that is revised or changed as a result of 
informal dispute resolution must be disclosed to the ombudsman in accordance with 
7904. 
 
Deficiencies pending informal dispute resolution should be entered into the Automated 
Survey Processing Environment system (ASPEN) and the ASPEN Informal Dispute 
Resolution (IDR) Manager within ten (10) calendar days of receiving the request for an 
informal dispute resolution.  This information however will not be uploaded to the 
Certification and Survey Provider Enhanced Reporting system (CASPER) for posting to 
the Nursing Home Compare website until informal dispute resolution has been 
completed.  
  7.   A facility may request informal dispute resolution for each survey that cites 
deficiencies.  However, if informal dispute resolution is requested for deficiencies 
cited at a subsequent survey, a facility may not challenge the survey findings of a 
previous survey for which the facility either received informal dispute resolution 
or had an opportunity for it.  The following table indicates when informal dispute 
resolution may be requested based on the results of a revisit or as a result of the 
previous informal dispute resolution outcome.  
 
  Eligibility for Informal Dispute 
Situation  Resolution 
   
Continuation of same deficiency at revisit  Yes 
   
New deficiency (i.e., new or changed facts,  Yes 
new tag) at revisit or as a result of an 
informal dispute resolution 
   
New instance of deficiency (i.e., new facts,  Yes 
same tag) at revisit or as a result of an 
informal dispute resolution. 
   
Different tag but same facts at revisit or as a  No, unless the new tag 
result of an informal dispute resolution  constitutes substandard quality of 
care 
 
8.  Written description of the surveying entitys informal dispute resolution process 
must be made available to a facility upon the facilitys request. 
 
9.  States are encouraged to include in the informal dispute resolution process at least 
one person as part of the decision making process who was not directly involved 
in the survey.  This may include, but is not limited to, another surveyor, 
ombudsman, a member of another survey team, etc. 
 
7212.4 - Additional Elements for Federal Informal Dispute Resolution 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
In addition to those elements cited in 7212.3, CMS has adopted the following elements 
to be incorporated in all cases involving deficiencies cited as a result of Federal surveys.  
They are designed to clarify and expedite the resolution process.  States are free to 
incorporate these elements into their procedures. 
 
1.  Notice to the facility will indicate that the informal dispute resolution, including 
any face-to-face meetings, constitutes an informal administrative process that in 
no way is to be construed as a formal evidentiary hearing. 
  2.  Notice to the facility will indicate that counsel may accompany the facility.  If the 
facility chooses to be accompanied by counsel, then it must indicate that in its 
request for informal dispute resolution, so that CMS may also have counsel 
present. 
 
3.  CMS will verbally advise the facility of CMSs decision relative to the informal 
dispute, with written confirmation to follow. 
 
7213 - Independent Informal Dispute Resolution (Independent IDR) 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
All regulatory references are in 42 CFR unless otherwise stated. 
 
7213.1 - Introduction 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Under sections 1819(h)(2)(B)(ii)(IV) and 1919(h)(2)(B)(ii)(IV) of the Act and 
regulations at 42 CFR 488.331 and 488.431 SNFs, NFs and SNF/NFs are provided the 
opportunity to request and participate in an Independent IDR if CMS imposes civil 
money penalties against the facility and these penalties are subject to being collected and 
placed in an escrow account pending a final administrative decision. 
 
NOTE: All CMP funds are subject to escrow.  If the nursing home elects not to request 
an Independent IDR or to appeal, then after any IDR (if requested), CMP amount 
becomes due and payable in accordance with the process in 7528.3. 
 
A State survey agency does not need to create any new or additional processes for 
Independent IDR if its existing process meets the requirements at 42 CFR 488.331 and 
488.431 and described throughout 7213.   
 
7213.2  Purpose 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
To provide facilities, under certain circumstances, an additional opportunity to informally 
dispute cited deficiencies through a process that is independent from the State survey 
agency or, in the case of Federal surveys, the CMS Location.  
 
7213.3 - Independent Informal Dispute Resolution Requirements 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The requirements and specific core elements that must be included in an acceptable 
Independent IDR process are specified in the regulations at 42 CFR 488.331 and 488.431.  
CMS retains ultimate authority for the survey findings and imposition of civil money 
penalties.  However, an opportunity for an Independent IDR is provided within 30 
calendar days of the notice of imposition of a civil money penalty that is subject to being 
collected and placed in escrow.  An Independent IDR will    
1.  Be completed within 60 calendar days of a facilitys request, if an Independent 
IDR is requested timely by the facility; 
 
NOTE: Independent IDR is completed when a final decision from the 
Independent IDR process has been made, a written record has been generated 
and the State survey agency has sent written notice of this decision to the 
facility.  The Independent IDR process is also considered to be completed if a 
facility does not timely request or chooses not to participate in the Independent 
IDR process.   
 
2.  Generate a written record prior to the collection of the penalty; 
 
3.  Include notification to an involved resident or resident representative, as well as 
the States long term care ombudsman, to provide opportunity for written 
comment; 
 
NOTE: Involved resident is a resident who was the subject of a complaint or 
who filed a complaint that led to a deficiency finding that is the subject of 
Independent IDR.  Representative means either the residents legal 
representative or an individual filing a complaint involving or on behalf of a 
resident.  
 
4.  Be approved by CMS and conducted by the State, or by an entity approved by the 
State and CMS, or by CMS or its agent in the case of surveys conducted only by 
Federal surveyors where the State Independent IDR  process is not used, and 
which has no conflict of interest, such as: 
 
a.  A component of an umbrella State agency provided that the component is 
organizationally separate from the State survey agency, or 
 
b.  An independent entity with a specific understanding of Medicare and 
Medicaid program requirements selected by the State and approved by 
CMS, and, 
 
5.  Not include the survey findings that have already been the subject of an informal 
dispute resolution under 488.331 for the particular deficiency citations at issue in 
the independent process under 488.431, unless the informal dispute resolution 
under 488.331 was completed prior to the imposition of the civil money penalty. 
 
The Independent IDR process, as established by the State survey agency, must be 
approved by CMS.  If an Independent IDR entity or person provides services in multiple 
States and/or CMS Location, each State and its CMS Location must approve the 
Independent IDR entitys or persons process and procedures for the States or CMS 
Locations jurisdiction.  In order to ensure compliance of the Independent IDR process 
with Federal statute and regulations, each State survey agency will submit its written  process and procedures, including any subsequent changes, to the applicable CMS 
Location for review and prior approval. The Independent IDR process must be in writing 
and available for review upon request. 
 
7213.4 - Applicability of the Independent Informal Dispute Resolution 
Process 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
The Independent IDR process must be offered to a facility when a civil money penalty is 
imposed and that penalty is subject to being collected and placed in escrow under 42 CFR 
488.431(b).  Beginning on January 1, 2012, CMS may collect and place imposed civil 
money penalties in an escrow account on whichever of the following occurs first: 
 
  The date on which the Independent IDR process is completed, or 
  The date which is 90 calendar days after the date of the notice of imposition of the 
civil money penalty. 
 
The Independent IDR is conducted only upon the facilitys timely request. The facility 
must request an Independent IDR within 10 calendar days of receipt of the offer. The 
facilitys request will be considered timely if the request is dated within 10 calendar days 
of the receipt of the offer, and, in the case of the request being mailed, the postmark 
verifies that it was mailed within that same 10 day time period. 
  
1.  A facility may request an Independent IDR for each survey that cites deficiencies 
for which a civil money penalty has been imposed that is subject to collection and 
placement in an escrow account.  However, when a facility requests an 
Independent IDR for a survey, the facility cannot raise questions or issues 
regarding a previous survey, and consideration of such previous survey results is 
beyond the scope of the independent IDR.  The following table indicates when 
independent informal dispute resolution may be requested based on the results of 
a revisit or as a result of the previous independent informal dispute resolution 
outcome.  
 
  Eligibility for Independent 
Situation  Informal Dispute Resolution 
   
Continuation of same deficiency at revisit  Yes 
which results in the continuation of the 
imposed civil money penalty  
   
New deficiency resulting in the imposition  Yes 
of a civil money penalty(i.e., new or 
changed facts, new tag) at revisit or as a 
result of an independent informal dispute 
resolution 
      Eligibility for Independent 
Situation  Informal Dispute Resolution 
New instance of deficiency resulting in the  Yes 
imposition of a civil money penalty (i.e., 
new facts, same tag) at revisit or as a result 
of an informal dispute resolution. 
   
Different tag but same facts at revisit or as a  No, unless the new tag 
result of an informal dispute resolution  constitutes substandard quality of 
care and results in the imposition 
of a civil money penalty 
 
The Independent IDR process does not delay the imposition of any remedies, including a 
civil money penalty.  During the Independent IDR process a facility may dispute the 
factual basis of the cited deficiencies for which it requested Independent IDR.  During the 
Independent IDR process, a facility may not challenge other aspects of the survey 
process, such as: 
 
  Scope or severity classifications, with the exception of  assessments that 
constitute substandard quality of care or immediate jeopardy; 
 
  Remedy(ies) imposed; 
 
  Alleged failure of the survey team to comply with a requirement of the survey 
process; 
 
  Alleged inconsistency of the survey team in citing deficiencies among other 
facilities; 
 
  Alleged inadequacy or inaccuracy of the IDR or Independent IDR process. 
 
The focus of the Independent IDR process is the deficiency or deficiencies from a survey 
that led to the imposition of a civil money penalty that is subject to being collected and 
placed in escrow under 488.431(b).  However, while such factors as the scope and 
severity classification, and the amount of the penalty, are not the subjects of the 
Independent IDR, State survey agencies and CMS, will take into consideration any 
changes in deficiency findings that result pursuant to State or CMS review of the 
completed Independent IDR process.  Based on such review, States and CMS will assess 
whether any changes to scope and severity or civil money penalty amount are warranted. 
 
While States have discretion to limit participation in the Independent IDR process by 
attorneys or other parties, notice to the facility should indicate that the Independent IDR, 
including face-to-face meetings, constitutes an informal administrative process that is not 
to be construed as a formal evidentiary hearing. 
  Independent IDR is not intended to be a formal or evidentiary hearing nor are the results 
of the Independent IDR process an initial determination that gives rise to appeal rights 
pursuant to 42 CFR 498.3(b).  The Independent IDR results are recommendations to the 
State and CMS and are not subject to a formal appeal. 
 
7213.5- Key Elements of Independent Informal Dispute Resolution 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
At a minimum, the Independent IDR process must provide for the following: 
 
1.  Offer of Independent IDR:  The opportunity for Independent IDR must be 
provided within 30 calendar days of CMSs notice of imposition of a civil money 
penalty that is subject to being collected and placed in an escrow account.  The 
CMS Location will communicate the offer for an Independent IDR in its initial 
Notice of Imposition of a Penalty letter to a facility.  In addition, the CMS notice 
will provide the State survey agency contact information, including the name, 
address, and telephone number of the person and/or agency or office that the 
facility must contact to request an Independent IDR.  The Notice of Imposition of 
a Penalty may be sent by e-mail and/or fax.  The Statement of Deficiencies (Form 
CMS-2567) may be included with the Notice of Imposition of a Penalty letter.  
The CMS Location must confirm receipt by the facility of such notice letter.  A 
copy of this letter will also be sent to the State survey agency. 
 
Upon a facilitys timely request for an Independent IDR, the State survey agency, or the 
Independent IDR entity or person (as appropriate) will provide the following information 
to the facility: 
 
  Information on the Independent IDR process including where, when and 
how the process may be accomplished, e.g., by telephone, in writing, or in 
a face-to-face meeting, and 
 
  Contact information, i.e. the name, address, phone number and e-mail of 
the person(s) who will be conducting the Independent IDR, if appropriate. 
 
As with the current IDR process, the Independent IDR process will be available to a 
facility at no charge.  Collected civil money penalty funds may not be used to cover State 
expenses for IDR or Independent IDR.  IDR and Independent IDR are part of the survey 
and certification process. 
 
2.  Timing:  The Independent IDR is conducted only upon the facilitys timely 
request.  The facility must request an Independent IDR within 10 calendar days of 
receipt of the offer.  The facilitys request will be considered timely if the request 
is dated within 10 calendar days of the receipt of the CMS offer, and, in the case 
of the request being mailed, the postmark verifies that it was mailed within that 
same 10 day time period. The facility must submit its request in writing to the 
State survey agency, or the approved Independent IDR entity or person, as  appropriate.  The facilitys request should also include copies of any documents, 
such as facility policies and procedures, resident medical record information that 
are redacted to protect confidentiality and all patient identifiable information, or 
other information on which it relies in refuting the survey findings. 
 
488.431(a)(1) require that the Independent IDR be completed within 60 days of the 
facilitys request.  Every effort must be made to comply with this time frame, however, 
failure to comply with the Independent IDR process does not invalidate any cited 
deficiencies or any remedies imposed.  
 
The Independent IDR process should be completed as soon as practicable but no later 
than 60 calendar days of receipt of the facilitys request. The Independent IDR process is 
considered completed if a facility does not timely request or chooses not to participate in 
the Independent IDR process or when a final decision has been made, a written record 
has been generated, AND the State survey agency has sent written notice of this final 
decision to the facility.  
 
3.  Opportunity to Comment:  Once a facility requests an Independent IDR, the 
State must notify the involved resident or resident representative, as well as the 
States long term care ombudsman, that they have an opportunity to submit 
written comment. The State should request information from the long-term care 
ombudsman program, asking for specific information based on the ombudsman 
programs direct involvement or knowledge and directly related to the deficiency 
(ies) being disputed by the facility.  Information about the facility or provider in 
general, but not related to the deficiency (ies) at issue, is not relevant to the 
Independent IDR process.   This notification must be done before the Independent 
IDR review begins and with sufficient time for the resident or their representative 
to provide comment.  At a minimum, this notification must include: 
 
  A brief description of the findings of noncompliance for which the facility is 
requesting Independent ID, a statement about the CMP imposed based on 
these findings, and reference to the relevant survey date; 
 
  Contact information for the State survey agency, or the approved Independent 
IDR entity or person as appropriate regarding when, where and how potential 
commenters must submit their comments; 
 
  A designated contact person to answer questions/concerns; 
 
  For residents and/or resident representatives, contact information for the 
States long term care ombudsman.   
 
4.  Written Record:  The Independent IDR entity or person must generate a written 
record as soon as practicable but no later than within 10 calendar days of 
completing its review.  The Independent IDR entity or person will forward the 
written record to the State survey agency, for retention by the surveying entity.   The State survey agency will provide the final decision to the facility as soon as 
practicable but no later than 10 calendar days of its receipt of the written record.  
The final Independent IDR decision to the facility shall contain the result for each 
deficiency challenged and a brief summary of the rationale for that result.  The 
written record from the Independent IDR entity or person shall include: 
 
  List of each deficiency or survey finding that was disputed; 
 
  A summary of the Independent IDR recommendation for each deficiency 
or finding at issue and the justification  for that result; 
 
  Documents submitted by the facility to dispute a deficiency, to 
demonstrate that a deficiency should not have been cited, or to 
demonstrate a deficient practice should not have been cited as immediate 
jeopardy or substandard quality of care; and, 
 
  Any comments submitted by the States long term care ombudsman and/or 
residents or resident representatives, as appropriate, taking care to protect 
confidentiality and protected health information. 
 
7213.6 - Qualifications of an Independent Informal Dispute Resolution 
Entity or Person(s) 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
In order to be approved as an Independent IDR entity or person, whether it is a State 
agency or an outside organization contracted by the State agency, the entity or person 
must meet the following requirements: 
 
Expertise and Training: The entity or person has an understanding of: 
 
  Medicare and Medicaid program requirements including, but not limited to: 
 
a)  42 CFR Part 483, Subpart B, and Part 488, Subparts A, E and F; 
b)  The State Operations Manual (SOM), including; 
1)  Chapter 7, Definitions and  7212, 7213  and 7900;  
2)  Appendix P, Appendix PP, Appendix Q; and 
 
  Applicable health care standards of practice, health care management, and/ or life 
safety code knowledge and experience, relevant to the disputed issues. 
 
Independence:  The entity or person  
 
  Has no financial or other conflict of interest; 
 
  May be a component of an umbrella State agency provided that the component is 
organizationally separate from the State survey agency;   
  May be an independent entity or person with an understanding of specific 
Medicare and Medicaid program requirements selected by the State and approved 
by CMS. 
 
Examples of possible conflict of interest include, but are not limited to, individuals who: 
 
a)  Were employed by the State survey agency or the State ombudsman program 
within the past year;  
 
b)  Have a family member who is either a resident or an employee of the facility 
involved in the Independent IDR; 
 
c)  Is currently employed by the facility or organization involved in the Independent 
IDR; 
 
d)  Have worked within the past year as an employee, consultant or volunteer for the 
facility or a related corporation, involved in the Independent IDR; 
 
e)  Have ownership interest or currently serves or within the past year has served on 
the Board of Directors or Governing Body of a facility or organization involved in 
the Independent IDR; or 
 
f)  Have acted within the past year as legal counsel for or against the facility 
involved in the Independent IDR. 
 
7213.7 - Approval of an Independent Informal Dispute Resolution 
Process 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
A States Independent IDR process must be approved by CMS.  The State must submit 
all proposed processes, including any process that may have been used by or already 
existed in the State prior to January 1, 2012, to the CMS Location for approval. 
 
The CMS Location will review and approve all written policies and procedures of the 
States Independent IDR process.  Any subsequent changes to an approved Independent 
IDR process must be submitted as soon as possible to the applicable CMS Location for 
review and approval prior to these changes taking effect. 
 
The State survey agency and the Independent IDR entity or person must enter into a 
written contract or Memorandum of Understanding (MOU) which ensures that the 
Independent entity or person meets all of the qualifications and responsibilities set forth 
in regulations and guidelines specified in Chapter 7, 7213.7 of the SOM and will 
comply with all applicable Federal record laws and regulations concerning protected 
health information and the survey process or the Independent IDR process.  An 
Independent IDR entity or person must not disclose to the public any information related  to the facility that requested the Independent IDR, including the results of the 
Independent IDR review. 
 
7213.8 - State Budget and Payment for Expenses 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Costs incurred by the State survey agency for conducting Independent IDRs are eligible 
for federal funding using standard cost allocation principles.  If the State has a State law 
or regulation that obliges the State to offer an Independent IDR, or specifies the manner 
in which an Independent IDR is to be provided, or who must provide the Independent 
IDR, then the State must use the existing cost allocation methodology and proportions in 
place for the States surveys of Skilled Nursing Facilities (SNF)/Nursing Facilities (NF), 
with costs allocated between Medicare, Medicaid, and State-only sources, as appropriate.  
In all other cases, the costs should be allocated between Medicare and Medicaid using the 
existing cost allocation methodology and proportions in place for the States surveys of 
Skilled Nursing Facilities (SNF)/Nursing Facilities (NF), but adjusted for the absence of 
a State-only share (that is, there would not need to be State-only funds beyond the 
requirement for State match for the Medicaid portion).  
 
States may not charge facilities for the Independent IDR process required under 42 
C.F.R. 488.431.  For deficiencies that are the basis for a CMP which is not collected and 
placed in escrow under 488.431(b), or for deficiencies that lead to the imposition of 
another remedy that is not a CMP, a State is not required to provide Independent IDR.  In 
situations where the Independent IDR process is not required but is provided by the State 
directly at its option, the State may choose to charge a facility a user fee for those 
processes.  
 
7213.9 - Independent Informal Dispute Resolution Recommendation 
and Final Decision 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
1.  Upon receipt of the Independent IDR written record, the State survey agency, will 
review the Independent IDR recommendation(s) and: 
 
(a) If the State survey agency, agrees with the Independent IDR 
recommendation(s) and no changes will be made to the disputed survey 
findings, the State survey agency will send written notification of the final 
decision to the facility within 10 calendar days of receiving the written 
record from the Independent IDR entity or person. 
 
(b) If the State survey agency disagrees with one or more of the 
recommendations of the Independent IDR entity or person, the complete 
written record will be sent to the applicable CMS Location for review and 
final decision.  The State survey agency should identify the portion(s) of 
the Independent IDR recommendation with which it disagrees, the basis 
for its disagreement including any relevant survey documents that support  its recommendation to the CMS Location.  As soon as practicable, but no 
later than 10 calendar days, the CMS Location will review the 
Independent IDR recommendation and records along with the States 
written disagreement of the Independent IDRs recommendation and will 
provide written notification to the State survey agency of the final 
decision.  The CMS review will be conducted by persons familiar with 
LTC requirements but who have not had any input or activity with respect 
to the survey or deficiencies at issue.  The State survey agency will then 
send written notification of the final decision to the facility within 10 
calendar days of receiving the final decision from the CMS Location.   
 
NOTE:  Regulations at 488.431(a) (1) require that an Independent IDR will be 
completed within 60 days of a facilitys timely request.  Completed means that a final 
decision from the Independent IDR process has been made, a written record generated 
AND the State survey agency has sent written notice of the Independent IDR 
recommendation to the facility. The Independent IDR process is also considered 
completed if a facility does not timely request or chooses not to participate in the 
Independent IDR process.   
 
2.  If the State survey agency agrees with the Independent IDR recommendation(s) or 
has received a final decision from the CMS Location and changes will need to be 
made to the disputed survey findings, the State survey agency will , within 10 
calendar days of receiving the written record: 
 
a)  Change deficiency(ies) citation content findings, as recommended; 
 
b)  Adjust the scope and severity assessment for deficiencies, if warranted by 
CMS policy after taking into consideration recommendations from the 
Independent IDR regarding the deficiency(ies); 
 
c)  Annotate deficiency(ies) citations as deleted or amended as 
recommended, where appropriate; 
 
d)  Have a State survey agency manager or supervisor sign and date the revised 
CMS Form-2567; 
 
e)  Promptly recommend to CMS that any enforcement action(s) imposed 
solely because of deleted or altered deficiency citations be reviewed, 
changed or rescinded as appropriate; and 
 
f)  Provide written notification of the final decision to the facility. 
 
NOTE: Based on a final Independent IDR recommendation and final State and CMS 
action, if one or more deficiencies on the Form CMS-2567 have been changed, deleted or 
altered, the facility has the option to request a clean (new) copy of the Form CMS-2567. 
However, the clean copy will be the releasable copy only when a clean (new) plan of  correction is both provided and signed by the facility. The original Form CMS-2567 is 
disclosable when a clean plan of correction is not submitted and signed by the facility. 
Any Form CMS-2567 and/or plan of correction that is revised or changed as a result of 
informal dispute resolution must be disclosed to the ombudsman in accordance with 
7904. 
 
Deficiencies pending Independent IDR should be entered into the Automated Survey 
Processing Environment (ASPEN) and the ASPEN Informal Dispute Resolution (IDR) 
Manager within ten (10) calendar days of receiving the request for an independent 
informal dispute resolution.   
 
IDR or Independent IDR requests from the facility should be entered in the ASPEN 
system within 10 working days of the IDR or Independent IDR request and necessary 
changes should be entered in the ASPEN system within 10 working days of completion 
of the IDR or Independent IDR process.  
Specific instructions are provided in the current ASPEN Users Guides 
 
7213.10 - Additional Elements for Federal Independent Informal 
Dispute Resolution Process 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
In the case where a Federal survey, conducted solely by Federal surveyors, or its 
contractors, results in the imposition of a civil money penalty (CMP) that is subject to 
being collected and placed in escrow, the CMS Location will offer the facility the 
opportunity for an Independent IDR.  The CMS Location will follow the applicable 
elements cited in 7213.  The CMS Location should advise the facility that all requests 
for an Independent IDR should be directed in writing to the CMS Location and an 
electronic copy of the request should also be sent to the CMS mailbox at 
CMSQualityAssurance@cms.hhs.gov.  The facility should send any and all 
documentation, such as facility policies and procedures, resident medical record 
information or other information on which it relies in disputing the survey findings 
directly to the entity contracted by CMS to provide the Federal Independent IDR process. 
The facility must also send a copy of the supporting documentation to the CMS Location 
with its request.  
 
The CMS Location must also inform the involved resident or resident representative as 
well as the States long term care ombudsman to submit any written comments directly to 
the Federal Independent IDR entity.  This Independent IDR will be a paper review 
performed by the Federal Independent IDR entity under contract with CMS, Survey & 
Certification Group, Division of Nursing Homes.  The Independent IDR will be 
completed within 60 calendar days of the facilitys timely request.  Upon completion of 
the review the Federal Independent IDR entity will send all documents submitted by the 
facility and any comments submitted by the States long term care ombudsman and/or 
residents or resident representatives to the respective CMS Location along with its final 
written record/report. 
  In the event that any conflict of interest exists between the facility and the contracted 
Federal Independent IDR entity, or in the event that the Federal Independent IDR entity 
is unavailable, the Independent IDR will be conducted by CMS Headquarters .  In this 
case, the facility should be instructed to send all documentation to: 
 
Centers for Medicare & Medicaid Services 
Survey and Certification Group - Division of Nursing Homes 
7500 Security Blvd - Mailstop C2-21-16 
Baltimore, MD 21244 
 
This Independent IDR will be a paper review performed by a panel of CMS 
Headquarters  employees who meet the criteria for an Independent IDR entity.  The 
Independent IDR will be completed within 60 calendar days of the facilitys timely 
request.  Upon completion of the review, CMS Headquarters  will send all documents 
submitted by the facility and any comments submitted by the States long term care 
ombudsman and/or residents or resident representatives to the respective CMS Location 
along with their final written record/report. 
 
Upon receipt of a facilitys request for an Independent IDR the CMS Location should 
enter the appropriate information into the Automated Survey Processing Environment 
(ASPEN). 
 
Upon receipt of the Independent IDR written record, the CMS Location, will review the 
Independent IDR recommendation(s) and: 
 
1.  If the CMS Location agrees with the Independent IDR recommendation(s) and no 
changes will be made to the disputed survey findings, the CMS Location will send 
written notification of the final decision to the facility within 10 calendar days of 
receiving the written record from the Independent IDR entity or person. 
 
2.  If the CMS Location disagrees with one or more of the recommendations of the 
Independent IDR entity or person, the complete written record will be sent to 
CMS Headquarters  for review and final decision.  The CMS Location should 
identify the Independent IDR recommendation with which it disagrees, the basis 
for its disagreement and any relevant survey documents to CMS Headquarters .  
As soon as practicable, but no later than 10 calendar days, CMS Headquarters  
will review the Independent IDR recommendation and corresponding records 
along with the CMS Locations written disagreement of the Independent IDRs 
recommendation and will provide written notification to the CMS Location of the 
final decision.  The CMS Location will then send written notification of the final 
decision to the facility within 10 calendar days of receiving the final decision 
from  CMS Headquarters .   
 
NOTE:  The regulations at 488.431(a) (1) require that an Independent IDR will be 
completed within 60 days of a facilitys timely request.  Completed means that a final 
decision from the Independent IDR process has been made, a written record generated  AND the CMS Location has sent written notice of the Independent IDR recommendation 
to the facility. 
 
3.  If the CMS Location agrees with the Independent IDR recommendation(s) or has 
received a final decision from CMS Headquarters  and changes are to be made to 
the disputed survey findings, the CMS Location will, within 10 calendar days of 
receiving the written record: 
 
a)  Change deficiency (ies) citation content findings, as recommended; 
 
b)  Adjust the scope and severity assessment for deficiencies, if warranted by 
CMS policy after taking into consideration approvable recommendations 
from the Independent IDR regarding the deficiency (ies); 
 
c)  Annotate deficiency (ies) citations as deleted or amended as 
recommended where appropriate; 
 
d)  Have a CMS Location manager or supervisor sign and date the revised 
CMS Form-2567; 
 
e)  Ensure that any enforcement action(s) imposed solely because of deleted 
or altered deficiency citations will be reviewed, changed or rescinded, as 
appropriate; and 
f)  Provide written notification of the final decision to the facility.  
NOTE: Based on a final Independent IDR recommendation and final State and CMS 
action, if one or more deficiencies on the Form CMS-2567 have been revised or removed, 
the facility has the option to request a clean (new) copy of the Form CMS-2567. 
However, the clean copy will be the releasable copy only when a clean (new) plan of 
correction is both provided and signed by the facility. The original Form CMS-2567 is 
disclosable when a clean plan of correction is not submitted and signed by the facility. 
Any Form CMS-2567 and/or plan of correction that is revised or changed as a result of 
IDR must be disclosed to the ombudsman in accordance with 7904. 
 
Deficiencies pending Independent IDR should be entered into the Automated Survey 
Processing Environment (ASPEN) and the ASPEN Informal Dispute Resolution (IDR) 
Manager.  
 
IDR or Independent IDR requests from the facility and necessary changes should be 
entered in the ASPEN system within 10 working days of the IDR or Independent IDR 
request and necessary changes should be entered in the ASPEN system within 10 
working days of completion of the IDR or Independent IDR process.  
 
Specific instructions are provided in the current ASPEN Users Guide. 
  The ASPEN Enforcement Manager (AEM) will be enabled to include the Independent 
IDR process for enforcement actions with survey cycles that begin on or after January 1, 
2012. 
 
7300 - Certification of Compliance and Noncompliance for Skilled 
Nursing Facilities and Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7300.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
These procedures are established pursuant to sections 1819(g) and 1919(g) of the Act and 
42 CFR 488.330 to provide guidance about when the State or the CMS Location has the 
responsibility for certifying compliance or noncompliance and what procedures to follow. 
This section also defines the concept of substantial compliance for certification 
purposes. 
 
The State has the responsibility for certifying a skilled nursing facilitys or nursing 
facilitys compliance or noncompliance, except in the case of State-operated facilities.  
However, the States certification for a skilled nursing facility is subject to CMSs 
approval.  Certification of compliance means that a facilitys compliance with Federal 
participation requirements is ascertained.  In addition to certifying a facilitys compliance 
or noncompliance, the State recommends appropriate enforcement actions to the State 
Medicaid Agency for Medicaid and to the CMS Location for Medicare.  The State is 
authorized by CMS to both recommend and impose category 1 remedies.  In addition, 
when authorized by the CMS Location or the State Medicaid Agency, the State may also 
provide notice of imposition of the denial of payment for new admissions remedy.  As 
specified in 42 CFR 488.10, the CMS Location determines a facilitys eligibility to 
participate in the Medicare program based on the States certification of compliance and 
a facilitys compliance with civil rights requirements. 
 
Throughout this chapter, references are made to the State Medicaid Agency in taking 
enforcement actions against a Medicaid facility.  However, there is nothing in Federal 
regulation that precludes the State Medicaid Agency from delegating the authority to act 
on its behalf in imposing enforcement remedies for Medicaid nursing facilities. The CMS 
Location has the responsibility for certifying a State-operated skilled nursing facilitys or 
nursing facilitys compliance or noncompliance. In accordance with 1919(h)(3), the 
CMS Location may take independent and binding enforcement action against any nursing 
facility based on its findings of noncompliance.  However, the CMS Locations 
certification is usually based on the States survey and findings. 
 
7300.2 - Survey and Certification Responsibility 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
  Except as specified in 7300, the following entities are responsible for surveying and 
certifying a skilled nursing facilitys or nursing facilitys compliance or noncompliance 
with Federal requirements: 
 
  State-Operated Skilled Nursing Facilities or Nursing Facilities or State-
Operated Dually Participating Facilities - The State conducts the survey, but 
the CMS Location certifies compliance or noncompliance and determines whether 
a facility will participate in the Medicare or Medicaid programs. 
 
  Non-State Operated Skilled Nursing Facilities - The State conducts the survey 
and certifies compliance or noncompliance, and the CMS Location determines 
whether a facility is eligible to participate in the Medicare program.  
 
  Non-State Operated Nursing Facilities - The State conducts the survey and 
certifies compliance or noncompliance.  The States certification is final.  The 
State Medicaid Agency determines whether a facility is eligible to participate in 
the Medicaid program. 
 
  Non-State Operated Dually Participating Facilities (Skilled Nursing 
Facilities/Nursing Facilities) - The State conducts the survey and certifies 
compliance or noncompliance.  The States certification of compliance or 
noncompliance is communicated to the State Medicaid Agency for the nursing 
facility and to the CMS Location for the skilled nursing facility.  In the case where 
the State and the CMS Location disagree with the certification of compliance or 
noncompliance, see 7807 for rules to resolve such disagreements. 
 
7300.3 - Initial Survey and Certification Responsibility 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The State determines whether a prospective provider is in substantial compliance with the 
nursing home participation requirements.  If the facility is in substantial compliance, the 
State certifies and recommends that the CMS Location and/or State Medicaid Agency 
enter into an agreement with the facility.  Using the guidance below about the methods by 
which substantial compliance may be determined, if the facility is determined not to be in 
substantial compliance, the State recommends that the CMS Location and/or State 
Medicaid Agency deny participation.  The CMS Location and/or State Medicaid Agency 
sends the letter notifying the facility of its denial of participation in the Medicare and/or 
Medicaid programs, and includes the appeal rights available under 42 CFR 431.153 and 
42 CFR 498.3(b).  (See also 2005 and 7203 of this manual.) 
 
With the exception of an initial survey for reasonable assurance, if the initial survey of 
the prospective provider finds that the noncompliance is such that the deficiencies fall at 
levels D, E, or F (without a finding of substandard quality of care) on the scope and 
severity scale, the State survey agency may opt to accept evidence of correction to 
confirm substantial compliance in lieu of an onsite revisit; however, the State survey 
agency always has the discretion to conduct an onsite revisit to determine if corrections  have been made.  If the noncompliance falls at level F (with a finding of substandard 
quality of care), or any level higher than level F, the option to accept evidence of 
correction in lieu of an onsite revisit does not apply.  In this case, an onsite revisit is 
necessary to determine substantial compliance after the facility submits an acceptable 
plan of correction.  For reasonable assurance, deficiencies at level D or above on the first 
survey will result in denial for purposes of starting Medicare reasonable assurance.  (See 
7321.3.1.) 
 
The plan of correction does not assure the execution of a provider agreement.  The 
effective date of the provider agreement would be the date the survey agency verifies 
substantial compliance as determined by the appropriate evidence of correction as 
discussed above.   
 
With the exception of an initial survey for reasonable assurance, the option to accept 
evidence of correction in lieu of an onsite revisit is also applicable when an existing 
Medicaid nursing facility with deficiencies at levels D, E, or F (without substandard 
quality of care) wishes to participate as a Medicare skilled nursing facility. The survey 
agency does not conduct a new survey.  The survey agency submits the information 
obtained during the most recent Medicaid survey and other documentation as required, 
e.g., compliance with 42 CFR 483.30(c) and (d) and 42 CFR 483.40(e) and (f), for the 
initial certification of the Medicare nursing home to the CMS Location.  The Medicare 
provider agreement would be effective when the survey agency determines the facility is 
in substantial compliance either through evidence of correction submitted or by an onsite 
revisit.  For reasonable assurance, deficiencies at level D or above on the first survey will 
result in denial for purposes of starting Medicare reasonable assurance.  (See 7321.3.1.) 
 
When the State recommends that the CMS Location and/or State Medicaid Agency deny 
participation, the CMS Location and/or State Medicaid agency sends the letter notifying 
the facility of its denial of participation in the Medicare and/or Medicaid programs, and 
includes the appeal rights available under 42 CFR 431.153 and 42 CFR 498.3(b). 
 
7300.4 - Effect of CMS Validation Authority 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The CMS Location may make independent findings of compliance or noncompliance 
based on its own validation survey.  The CMS Locations finding of noncompliance is 
binding and takes precedence over the States certification of compliance based on the 
States survey. 
 
The CMS Location may also make independent findings of compliance or noncompliance 
based on its review of the States certification of compliance or noncompliance.  The 
CMS Location need not conduct an onsite visit in order to exercise its validation 
authority.  However, the CMS Locations determination of compliance based on the 
States findings that resulted in the States certification of noncompliance does not take 
precedence.  (See 7807 for resolving disagreements between the CMS Location and the 
State.)   
7301 - Action When Facility Is Not in Substantial Compliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7301.1 - Immediate Jeopardy Exists  
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
(See also 7307 and Appendix Q of this manual.) 
 
When immediate jeopardy exists: 
 
1.  The CMS Location or State Medicaid Agency will impose termination and/or 
temporary management in as few as 2 calendar days (one of which must be a 
working day) after the survey which determined immediate jeopardy. In all cases 
of immediate jeopardy, the provider agreement must be terminated by CMS or 
State Medicaid Agency no later than 23 calendar days from the last day of the 
survey if the immediate jeopardy is not removed. 
 
2.  The CMS Location or State Medicaid Agency should impose another remedy in 
addition to termination when immediate jeopardy has been determined.  
Immediate imposition of an alternative remedy should be considered even if the 
facility successfully removes the immediate jeopardy but is still not in substantial 
compliance. 
 
3.  The CMS Location or State Medicaid Agency may impose a civil money penalty 
between $3,050 and $10,000 per day of immediate jeopardy or a per instance 
civil money penalty from $1,000 to $10,000 for each deficiency.  The specific 
procedures for civil money penalties can be found in 7510-7536. 
 
4.  The CMS Location or State Medicaid Agency may impose other remedies as 
described in 7500.  Except for State monitoring, which requires no notice, the 
CMS Location or State Medicaid Agency may impose remedies 2 calendar days 
(one of which must be a working day) from the date the facility receives notice. 
 
5.  The CMS Location, State Medicaid Agency, or State (as authorized by CMS) may 
impose State monitoring immediately without notice. 
 
6.  The State, as authorized by CMS, may also provide notice of the imposition of 
denial of payment for new admissions effective 2 calendar days (one of which 
must be a working day) from the date the facility receives notice.  (See also 
7311, 7314, and 7506.1.) 
 
7.  The State will require that the facility submit an allegation that the immediate 
jeopardy has been removed as well as provide sufficient detail to demonstrate 
how the immediate jeopardy has been addressed so that the State can verify onsite 
the removal of the immediate jeopardy.  A plan of correction should be deferred  until the facility has successfully demonstrated removal of immediate jeopardy.  
Facilities should be cautioned that the allegation of removal of the immediate 
jeopardy does not guarantee a revisit before the effective date of termination. 
 
8.  The State will require an acceptable plan of correction for all deficiencies cited 
after it conducts the revisit to confirm removal of the immediate jeopardy. 
9.  The State is authorized to recommend and impose category 1 remedies.  When 
authorized by the CMS Location, the State may also provide notice of imposition 
and rescission of the denial of payment for new admissions remedy.  (See also 
7311, 7314, and 7506.1.) 
 
7301.2 - Immediate Jeopardy Does Not Exist 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
(See also 7310) 
 
When immediate jeopardy does not exist: 
 
1.  CMS or the State must determine whether the facility will be given an opportunity 
to correct its deficiencies before remedies are imposed (see 7304). 
 
2.  The CMS Location or State Medicaid Agency should impose another remedy in 
addition to termination for a facility not being given an opportunity to correct. 
 
3.  The CMS Location or State Medicaid Agency terminates the Medicare and/or 
Medicaid provider agreements that are in effect no later than 6 months from the 
date of the survey that determined noncompliance if noncompliance still exists 
(see 7600). Except for State monitoring, which requires no notice, the CMS 
Location or State Medicaid Agency may impose these remedies 15 calendar days 
from the date the facility receives notice. 
 
4.  When there is an opportunity to correct before remedies are imposed, the State 
will request an acceptable plan of correction, provide initial notice of 
recommended remedies (including recommendation for subsequent termination, 
conduct a revisit if applicable, then provide formal notice of denial of payment for 
new admissions (if authorized by the CMS Location) and other remedies if 
noncompliance continues at revisit.  While formal notice of imposition of denial 
of payment for new admissions by the State (if authorized by the CMS Location) 
is generally provided in the revisit letter, the State may provide such notice in its 
initial notice to the facility.  (See also 7305.1, 7311, 7313.2, 7314, 7316.2 
and 7506.1.) 
 
5.  The CMS Location or State Medicaid Agency must impose denial of payment for 
new admissions no later than 3 months after the last day of the survey that 
identified the noncompliance if substantial compliance is not achieved.   
6.  The CMS Location or State Medicaid Agency (or State, as authorized by CMS) 
may impose State monitoring without notice. 
 
7.  The CMS Location or State Medicaid Agency may impose either a per day civil 
money penalty between $50 and $3,000 per day or a per instance civil money 
penalty between $1,000 and $10,000 for each deficiency.  The specific procedures 
for civil money penalties can be found in 7510-7536. 
 
8.  The State is authorized to recommend and impose category 1 remedies.  When 
authorized by the CMS Location, the State may also provide notice of imposition 
and rescission of the denial of payment for new admissions remedy.  (See also 
7311, 7314, and 7506.1.) 
 
7301.3 - Prospective Providers 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
See 7203.2 and 7300.3. 
 
7303 - Appeal of Certification of Noncompliance 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
With the exception of the State monitoring remedy, facilities may appeal the finding of 
noncompliance that led to an enforcement remedy.  Enforcement includes termination, 
alternative remedies provided in 7400, and any alternative or additional State remedies 
approved by CMS.  Rather than sending an appeal to the CMS Location, facilities may 
appeal directly to the Departmental Appeals Board in the Office of the Secretary for 
Health and Human Services, with a copy to the State and CMS Location.  However, in 
the case of an enforcement action taken by the State against a Medicaid-only facility, the 
appeal should be sent to the State.  The appeal procedures for facilities are found at: 
 
  42 CFR Part 498 for State-operated skilled nursing facilities, nursing facilities or 
skilled nursing facilities/nursing facilities; 
 
  42 CFR Part 498 for non-State operated skilled nursing facilities or skilled 
nursing facilities/nursing facilities, and non-State nursing facilities for which the 
CMS Location disagrees with the States finding of compliance; and 
 
  42 CFR Part 431 for non-State operated nursing facilities in which the 
determination was made by the State Medicaid Agency or was subject to a 
validation review by the CMS Location and the CMS Location agrees with the 
States finding.  (See 7300.4 and 7311.2 for more information about CMS 
validation authority.) 
 
With the exception of civil money penalties, enforcement actions may be imposed while 
the facility is appealing the noncompliance that led to the enforcement action.  For  example, a facility could have its provider agreement terminated effective May 1, while 
the hearing of the facilitys appeal may not occur until after that date.  Except in the case 
of civil money penalties, a request for a hearing will not defer the effective date of the 
enforcement action.  Further, in accordance with 42 CFR 431 153(e)(2), a nursing 
facilitys request for a hearing on denial or termination does not delay the enforcement 
action and need not be completed before the effective date of the action.  In the case of 
civil money penalties, the hearing, if requested, must be completed before the civil 
money penalty can be collected.  However, the daily civil money penalty amount 
continues to accrue from the effective date until the facility is either terminated or has 
achieved substantial compliance. 
 
In accordance with 42 CFR 498.40(b), the content of the request for a hearing must 
identify the specific issues, the findings of fact and conclusions of law with which the 
facility disagrees, and specify the basis for contending that the findings and conclusions 
are incorrect. 
 
See 7809 for appeals of substandard quality of care that resulted in disapproval of a 
Nurse Aide Training and Competency Evaluation Program. 
 
7304 - Mandatory Immediate Imposition of Federal Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Noncompliance may occur for a variety of reasons and can result in harm to residents or 
put residents at risk for harm.  When facilities do not maintain substantial compliance, 
CMS may use various enforcement remedies to address a facilitys responsibility to 
promptly achieve, sustain and maintain compliance with all federal requirements.  To 
support this purpose, we are directing the immediate imposition of federal remedies in 
certain situations outlined in 7304.1 below, and we recommend using the type of 
remedy that best achieves the purpose based on the circumstances of each case. 
 
This guidance does not apply to past noncompliance deficiencies as described in 
7510.1 of this chapter.  The determination to impose a federal remedy for past 
noncompliance is not mandatory and is at the discretion of the CMS Location.   
 
7304.1 - Criteria for Mandatory Immediate Imposition of Federal 
Remedies Prior to the Facility's Correction of Deficiencies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
CMS will impose federal remedies and the survey will be identified as a No 
Opportunity to Correct if the situation meets any one or more of the following 
criteria: 
  Immediate Jeopardy (IJ) (scope and severity levels J, K, and L) is 
identified on the current survey; OR 
  Any deficiency from the current survey at levels G, H or I that falls into 
any of the regulatory sections that constitute Substandard Quality of Care 
(SQC); OR    Any deficiency at G or above on the current survey AND if there were any 
deficiencies at G or above on the previous standard health or LSC survey or 
if there was any deficiency at G or above on any type of survey between the 
current survey and the last standard health or LSC survey.  These surveys 
(standard health or LSC, complaint, revisit) must be separated by a certification 
of compliance, i.e., they must be from different noncompliance cycles.  For 
instance, level G or above deficiencies from multiple surveys within the same 
noncompliance cycle must not be combined to make this a double G or 
higher determination; OR 
  A facility classified as a Special Focus Facility (SFF) AND has a deficiency 
citation at level F, (excluding any level F citations under tags F812, F813 
or F814) or higher for the current health survey or G or higher for the 
current Life Safety Code (LSC) survey. 
 
The remedies to be imposed by statute do not change, (e.g., 3-month automatic 
Denial of Payment for new admissions (DPNA), 23-day termination when IJ is 
present and 6-month termination).  In addition to these statutory remedies, the 
CMS Location must also immediately impose one or more additional remedies for 
any situation that meets the criteria identified above.  The State Survey and/or 
Medicaid Agencies shall not permit changes to this policy. 
 
Use of Federal Remedies in Immediate Jeopardy (IJ) Citations - When IJ is 
identified on the current survey that resulted in serious injury, harm, impairment or 
death, a CMP must be imposed. 
 
For IJ citations where there is no resultant serious injury, harm, impairment or death 
but the likelihood is present, the CMS Location must impose a remedy or remedies 
that will best achieve the purpose of attaining and sustaining compliance.  CMPs may 
be imposed, but they are not required. 
 
NOTE: Current survey is whatever Health and/or LSC survey is currently being 
performed, e.g., standard, revisit, or complaint.  Standard survey (which does not 
include complaint or revisit surveys) is a periodic, resident-centered inspection that 
gathers information about the quality of service furnished in a facility to determine 
compliance with the Requirements of Participation. 
 
Process for State Enforcement Recommendations - While States are not required to 
recommend the types of remedies to be imposed, they are encouraged to do so since 
States may be more familiar with a facilitys history and the specific circumstances in 
the case at hand.  The CMS Location will consider these recommendations but 
ultimately makes the enforcement determination.  To ensure effective communication 
and exchange of information, CMS encourages that all documentation is included in the 
ASPEN -Enforcement Manager (AEM) system or any subsequent system. 
 
Regardless of a States recommendation, the CMS Location  must take the necessary 
actions to impose a remedy or multiple remedies, based on the seriousness of the  deficiencies following the criteria set forth in 42 C.F.R. 488.404.  Also refer to 
7400.5.1 and 7400.5.2 of this chapter.  In addition to any statutorily imposed remedy, 
additional remedies should be selected that will bring about compliance quickly and 
encourage facilities to achieve and maintain compliance.  When making remedy 
choices, the CMS Location  should consider the extent to which the noncompliance is 
the result of a one-time mistake, larger systemic concerns, or an intentional action of 
disregard for resident health and safety.  The surveyor investigation and corresponding 
CMS-2567 should provide evidence to assist with that determination. 
 
The State Survey Agency is authorized to both recommend and impose one or more 
Category 1 remedies, in accordance with 7314 of this Chapter.  CATEGORY 1 
remedies include: 
 
  Directed plan of correction, 
  State monitoring, and 
  Directed in-service training. 
 
Types of Remedies - The choice of remedy is made that best achieves the purpose of 
attaining and sustaining compliance based on the circumstances of each case and 
recommendations from the State.  Federal remedies are summarized below.  Refer to 
7500 - 7556 of this chapter for more detail on these remedies. 
 
Civil Money Penalties (CMPs) - Federal CMPs may only be imposed by the CMS 
Location. If a CMP is imposed, it must be done in accordance with instructions in the 
CMP Analytic Tool and 7510 through 7536 of this chapter. 
 
Directed In-Service Training  Refer to 7502 of this chapter.  Consider this remedy 
in cases where the facility has deficiencies where there are knowledge gaps in standards 
of practice, staff competencies or the minimum requirements of participation and where 
education is likely to correct the noncompliance.  Depending on the topic(s) that need to 
be addressed and the level of training needed, facilities should consider using programs 
developed by well-established centers of geriatric health services such as schools of 
medicine or nursing, centers for the aging, and area health education centers which have 
established programs in geriatrics and geriatric psychiatry.  If it is willing and able, a 
State may provide special consultative services for obtaining this type of training.  The 
State or CMS Location may also compile a list of resources that can provide directed in-
service training and could make this list available to facilities and interested 
organizations.  Facilities may also utilize the ombudsman program to provide training 
about residents rights and quality of life issues. 
 
Directed Plan of Correction - Refer to 7500 of this chapter.  This remedy provides 
for directed action(s) from either the State or CMS Location that the facility must take to 
address the noncompliance or a directed process for the facility to more fully address the 
root cause(s) of the noncompliance.  Achieving compliance is ultimately the facilitys 
responsibility, whether or not a directed plan of correction is followed. 
  Temporary Management - Refer to 42 CFR 488.408 and 488.410.  This is the 
temporary appointment by CMS or the State of a substitute facility manager or 
administrator with authority to hire, terminate or reassign staff, obligate facility funds, 
alter facility procedures, and manage the facility to correct deficiencies identified in the 
facility's operation.  A temporary manager may be imposed anytime a facility is not in 
substantial compliance but may also be imposed when a facilitys deficiencies constitute 
IJ or widespread actual harm and a decision is made to impose an alternative remedy in 
lieu of termination.  It is the temporary managers responsibility to oversee correction of 
the deficiencies and assure the health and safety of the facilitys residents while the 
corrections are being made.  The temporary managers term can extend beyond the time 
which deficiencies are corrected by agreement of the facility and the temporary manager.  
A temporary manager remedy may also be imposed to oversee orderly closure of a 
facility.  The State will select the temporary manager when the State Medicaid Agency is 
imposing the remedy and will recommend a temporary manager to the CMS Location 
when CMS is imposing the remedy.  Each State should compile a list of individuals who 
are eligible to serve as temporary managers.  These individuals do not have to be located 
in the State where the facility is located. 
 
Denial of Payment for all New Medicare and Medicaid Admissions (DPNA) - See 
7506 of this chapter.  This remedy may be imposed alone or in combination with 
other remedies to encourage quick compliance.  Regardless of any other remedies that 
may be imposed, a mandatory denial of payment for new admissions must be 
imposed when the facility is not in substantial compliance three months after the last 
day of the survey identifying deficiencies, or when a facility has been found to have 
furnished substandard quality of care on the last three consecutive standard surveys 
(see 42 CFR 488.414). 
 
Denial of all Payment for all Medicare and Medicaid Residents (DPAA) 
(Discretionary). - See 
7508 of this chapter. Only CMS has the authority to deny all payment for Medicare 
and/or Medicaid residents.  This is in addition to the authority to deny payment for all 
new admissions 
(discretionary) noted above.  This is a severe remedy.  Factors to be considered in 
selecting this remedy include but are not limited to: 
 
1.  Seriousness of current survey findings; 
2.  Noncompliance history of the facility; and 
3.  Use of other remedies that have failed to achieve or sustain compliance. 
 
State Monitoring - Refer to 7504 of this chapter.  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.  Consider 
imposing this remedy when, for example, there are concerns that the situation in the 
facility has the potential to worsen or the facility seems unable or unwilling to take 
corrective action.  A State monitor must be used when a facility has been cited with 
substandard quality of care (SQC) deficiencies on the last three consecutive standard  health surveys. 
 
Termination of Provider Agreement - See 7556 of this chapter.  While this remedy 
may be imposed at any time the circumstances warrant regardless of whether IJ is 
present; regardless of any other remedies that may be imposed, termination of a facilitys 
provider agreement must be imposed when the facility is not in substantial compliance 
six months after the last day of the survey identifying deficiencies or within no more than 
23 days if IJ is identified and not removed. 
 
Mandatory Criteria for Immediate Imposition of Federal 
Remedies 
 
Any G level 
Facilities 
deficiency is  Deficiencies of actual 
classified as a SFF 
identified on the  harm are identified on 
Mandatory  AND has a 
Deficiencies of   current survey in 42  the current survey 
Criteria for  deficiency citation 
Immediate  SQC that are  C.F.R. 483.13,  AND deficiencies of 
Immediate  of F level or 
Jeopardy is  not IJ  are  Resident Behavior  immediate jeopardy 
Imposition of  higher for the 
identified on the  identified on  and Facility  OR actual harm were 
Federal  current health 
current survey  the current  Practices, 42 C.F.R.  identified on any type 
Remedies  survey or G or 
survey  483.15, Quality of  of survey between the 
  higher for the 
Life, or 42 C.F.R.  current survey and the 
current LSC 
483.25, Quality of  last standard survey 
survey 
Care 
Types of  1. Termination  1. Termination  1. Termination  1. Termination  1. Termination 
Remedy(ies)  2. CMPs must be  2. CMPs  2. CMPs  2.  CMPs  2. CMPs 
that, at a  imposed  3. DDPNA  3. DDPNA  3.  DDPNA   3. DDPNA 
minimum,  immediately   4. Directed  4. Directed Plan of  4.  Temp. Mgmt.  4. Temp. Mgmt. 
should be  3. DDPNA1  Plan of  Correction  5.  State Monitoring  5. State 
considered for  4. Temp. Mgmt.  Correction  5. Directed In- 6.  Directed Plan of     Monitoring 
immediate  5. State  5. Directed In- service Training  Correction   6. Directed Plan of 
imposition by  Monitoring  service  6. Denial of  7.  Directed In-service  Correction  
CMS in  6. Directed Plan  Training  Payment for All  8.  Denial of Payment  7. Directed In-
addition to the  of Correction  6. Denial of  Individuals    for All Individuals    service 
CMPs when  7. Directed In- Payment for    8. Denial of 
immediate  service  All    Payment for All 
jeopardy is  8. Denial of  Individuals    Individuals 
cited,   Payment for   
mandatory 3- ALL 
month DPNA  Individuals2 
for new 
admissions or 
mandatory 6-
month 
termination, as 
required.   
NOTE: 
Multiple 
remedies may 
be imposed for 
any situation as 
appropriate. 
                                                 
1 DDPNA = Discretionary Denial of Payment for New Admissions 
2 This remedy shall ONLY be imposed by CMS and may not be imposed by a State Medicaid Agency.  A 
state survey agency may only impose Category 1 remedies if authorized by the CMS Location.  Within 5 business days from when the initial notice was sent to the facility the survey agency must assure 
Decisions,  that all cases that meet the criteria outlined in 7304.1 above are entered into ASPEN/AEM and that all of 
Responsibilities   these cases are referred to the CMS Location  for their imposition of remedies.  The CMS Location  must 
& Actions  take the necessary action to impose remedies as appropriate, regardless of a States recommendation for 
(refer to  imposition of remedies, based on the seriousness of the deficiencies following the criteria set forth in 42 
7304.3)  C.F.R. 488.404 - Factors to be considered in selecting remedies.  Civil Money Penalties (CMPs) must be 
imposed in accordance with instructions in the CMP Tool. 
 
NOTE:  Denial of Payment for New Admissions - Whenever a States remedy is unique 
to its State plan and has been approved by CMS, then that remedy may also be imposed 
by the CMS Location against a dually-participating facility in that State.  Therefore, if a 
States ban on admissions remedy is determined to be an acceptable State alternative, it 
must be understood that in dually participating facilities, CMS can impose a States ban 
on admissions remedy only with regard to all Medicare/Medicaid residents.  Only the 
State can ban admissions of private pay residents. 
 
 
7304.2 - Effective Dates for Immediate Imposition of Federal Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Once a remedy is imposed, it becomes effective as of the date specified in the notice 
letter for the remedy being imposed.  All remedies remain in effect and continue until the 
facility has demonstrated and is determined to be in substantial compliance.  Substantial 
compliance must be verified in accordance with 7317 of this chapter.  Substantial 
compliance may be determined to occur anytime between the latest correction date on the 
approved Plan of Correction (PoC) up until the date of the revisit.  The date of substantial 
compliance is determined by the date on which the evidence provided by the facility 
supports correction of deficiencies as determined by the Survey Agency.  
 
For Immediate Jeopardy (IJ) Situations: A facilitys removal of the conditions that 
caused the IJ may, at CMSs discretion, result in the rescission of the 23-day 
termination.  A per day CMP must be lowered when the survey agency has verified that 
the IJ has been removed but deficiencies at a lower level continue.  Refer to the CMP 
Analytic Tool instructions for determining the dates of a per day CMP.  However, CMS 
shall not rescind any other remedies imposed until the facility achieves substantial 
compliance or is terminated.  Remedies imposed must remain in effect, irrespective of 
when the IJ is removed, unless otherwise rescinded or revised as a result of legal 
proceedings.  Remedies will be immediately imposed and effectuated whether the IJ 
was: 
  removed during the survey, or, 
  removed in a subsequent IJ removal revisit before the 23rd day. 
 
 
 
 
 
  7304.3 - Responsibilities of the State Survey Agency and the CMS 
Location when there is an Immediate Imposition of Federal Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When federal remedies are to be immediately imposed as outlined in 7304: 
  Within five (5) business days after the last day of the current survey when any of 
the criteria in 7304.1 is met the survey agency must notify the CMS Location 
their review and action; and, 
  The CMS Location will review these cases within five (5) business days of receipt 
from the survey agency and decide if an immediate imposition of remedies is 
appropriate. 
 
Timeliness is important to ensure that remedies are imposed, and notices are sent to the 
facility before the effective dates of the remedies to be imposed and meet the timelines 
for notices as outlined in 7305 of this chapter. 
 
The survey agency (State or Federal) must enter all of these cases as a NO opportunity 
to correct into the Automated System Processing Environment (ASPEN)/ASPEN 
Enforcement Manager (AEM) system within five (5) business days of sending the initial 
notice to the facility.  The State Survey Agency and the CMS Location must have 
systems in place to routinely check and monitor the ASPEN-AEM database to identify 
cases that may require enforcement action or additional follow-up, as needed. 
 
 
7305 - Notice Requirements 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7305.1 - Initial Notices by Surveying Entity 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7305.1.1  When No Immediate Jeopardy Exists and an Opportunity to 
Correct Will be Provided Before Remedies Are Imposed 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
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 facilitys 
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 facilitys 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, 7311, 7313.2, 7314, 7316.2, and 7506.1.) 
 
e.  Provides that the States 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 substantial compliance 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 facilitys receipt of the CMS-2567 (see 7304.4).  The plan 
of correction will serve as the facilitys 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 facilitys 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, 
7311, 7313.2, 7314,7316.2, and 7506.1.) 
 
i.  Provides elements of an acceptable plan of correction (See 7304.4.); 
  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 States licensing board. 
 
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. 
 
7305.1.2  When No Immediate Jeopardy Exists and No Opportunity to 
Correct Will be Provided Before Remedies Are Imposed 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
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 7311, 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 facilitys receipt of the CMS-2567 (see 7304.4).  The plan 
of correction will serve as the facilitys allegation of compliance; 
 
e.  Informs the facility of the opportunity for 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 States licensing board;  
 
i.  Provides elements of an acceptable plan of correction.  (See 7304.4.) 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 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. 
 
7305.1.3  When Immediate Jeopardy Exists 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The surveying entity sends the initial notice to the facility of the following: 
 
a.  The nature of the immediate jeopardy, including regulatory cites or initial 
assessment of immediate jeopardy findings; 
 
b.  Requests an allegation of removal of immediate jeopardy, including evidence of 
steps taken to remove the immediate jeopardy.  The plan of correction will usually 
be deferred until immediate jeopardy has been determined to be removed; 
 
c.  Consequences of failure to submit an allegation of removal, e.g., provider 
agreement termination; 
 
d.  Remedies recommended with effective dates; 
 
e.  Opportunity for informal dispute resolution;  
 
f.  Opportunity for independent informal dispute resolution if a civil money penalty 
subject to being collected and placed in an escrow account is imposed;     
g.  Disapproval of  nurse aide training and competency evaluation program and 
competency evaluation program and appeal rights if the program loss is based on 
a finding of substandard quality of care;  
 
h.  When substandard quality of care is determined, the facility must provide the 
State with a list of the physicians of those residents who were found to be subject 
to the substandard quality of care.  The State must notify each attending physician 
and refer the administrator to the States licensing board; and, 
 
i.  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. 
 
j.  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 facilitys 
approved plan of correction, but no earlier than 2 calendar days from the 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 facilitys approved plan of correction but no earlier than 2 calendar days 
from the date of receipt of notice by the facility).  (See also 7301, 7313.2, 
7314, 7316.2, and 7506.1.) 
 
7305.2 - CMS Location, State Medicaid Agency, and State Formal 
Notices When Remedies are Imposed 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
7305.2.1 - Who Sends the Formal Notice of Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
A formal notice of remedies is sent by: 
 
a.  The State, in either its initial notice or in its first revisit notice for category 1 
remedies and denial of payment for new admissions, when and as authorized by 
CMS and/or the State Medicaid Agency; 
 
b.  The CMS Location for remedies other than those provided in accordance with 1a. 
above; for skilled nursing facilities, skilled nursing facilities/nursing facilities, and  nursing facilities where the CMS Location is taking the enforcement action; 
and/or, 
 
c.  The State Medicaid Agency for remedies other than those provided in accordance 
with a. above for nursing facilities. 
 
7305.2.2 - Contents of the Formal Notice of Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The formal notice of remedies is notification to the facility of the following: 
 
a.  Facts regarding when the survey occurred, which requirements were found out of 
compliance, and, where applicable, subsequent actions on the part of the State or 
facility; 
 
b.  Basis for the enforcement remedy, including termination (i.e., the facility has 
failed to achieve substantial compliance); 
 
c.  Enforcement remedy(ies) being imposed and the effective date; e.g., except for 
State monitoring and civil money penalties, no sooner than 2 calendar days or 15 
calendar days from the facilitys receipt of notice, depending on whether or not 
immediate jeopardy exists; 
 
d.  Appeal rights and how to request a formal appeal; and 
 
e.  The mandatory enforcement remedies not yet imposed that must occur at a later 
date if the facility continues to be out of compliance (i.e., mandatory denial of 
payment for new admissions and/or termination of the provider agreement). 
 
7305.2.3 - Required Time Periods for Formal Notice 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The notice period begins once the facility receives its notice as indicated below. 
 
a.  Immediate Jeopardy  2 calendar day notice 
 
Except for civil money penalties and State monitoring, notice must be given at 
least 2 calendar days before the effective date of the enforcement action. 
 
b.  No Immediate Jeopardy  15 calendar day notice 
 
Except for civil money penalties and State monitoring, notice must be given at 
least 15 calendar days before the effective date of the enforcement action.   
 
7305.2.4 - Nurse Aide Training and Competency Evaluation 
Program/Competency Evaluation Program  (Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Instructions and notification requirements for the disapproval of a nurse aide training and 
competency evaluation program or competency evaluation program can be found in 
4132 of this manual. See 7303 for appeal rights for loss of the program. 
 
7305.3 - Overlap of Notice of Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
 
1.  When the State recommends a category 1 remedy and/or a denial of payment for 
new admissions, and/or the CMS Location or State Medicaid Agency imposes any 
other category of remedies at the same time, the CMS Location or State Medicaid 
Agency will send the notice that includes both category 1 and/or denial of 
payment for new admissions, and other category remedies. 
 
2.  When the State recommends and provides notice, as authorized by the CMS 
Location or State Medicaid Agency, of a category 1 remedy and/or of imposition 
of denial of payment for new admissions, and the CMS Location or State 
Medicaid Agency imposes other category remedies at a later date, both the State 
and the CMS Location or the State and the State Medicaid Agency, send separate 
notices. 
 
7305.4 - Means of Sending Notice 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The notice shall be in writing and shall be addressed directly to the provider/facility; or to 
an individual, an officer, managing or general agent, or other agent authorized by 
appointment or law to receive the notice. 
 
The notice shall be dispatched through first-class mail, or other reliable means. Other 
reliable means refers to the use of alternatives to the United States mail in sending 
notices. Electronic communication, such as facsimile transmission, is equally reliable and 
on occasion more convenient than the United States mail.  If electronic means such as 
facsimile transmission are employed to send notice, the sender should maintain a record 
of the transmission to assure proof of transmission if receipt is denied. 
 
7307 - Immediate Jeopardy Exists 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7307.1 - Statutory and Regulatory Basis 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(h)(2)(A)(I), 1919(h)(1)(A), and 1919(h)(3)(B)(1) of the Act, as well as 
42 CFR 488.410, provide how cases involving immediate jeopardy will be processed.  In 
addition, Appendix Q of this manual discusses immediate jeopardy.    
7307.2 - Purpose 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Immediate action is required to remove the immediate jeopardy to resident health or 
safety (as defined in 42 CFR 488.301) and to subsequently correct the deficiencies. The 
application of the remedies of temporary management or termination, or both, is required 
to address immediate jeopardy situations.  While the use of other remedies in addition to 
temporary management or termination is allowed, the Act makes it clear that the 
enforcement action for noncompliant facilities with immediate jeopardy deficiencies is 
intended to be swift. 
 
7308 - Enforcement Action When Immediate Jeopardy Exists 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If at any time during the survey one or more team members identify a possible IJ, the 
team must meet immediately to confer.  If the team agrees that deficiencies pose an IJ, 
the team leader must contact, while on-site, its management to discuss the findings.  If it 
is determined that IJ exits the team must notify the facility administration, while on-site, 
of the IJ findings. 
 
When the State Survey Agency identifies IJ, it must notify the CMS Location, or the 
State Medicaid Agency, or both, as appropriate, so that either agency terminates the 
provider agreement within 23 calendar days of the last date of the survey, and/or appoints 
a temporary manager who must remove the IJ within 23 calendar days of the last date of 
the survey which identified the IJ.  When the CMS Location imposes termination of a 
Medicaid provider agreement, it notifies the State Medicaid Agency to terminate the 
agreement.  However, action can be taken more quickly than 23 days as long as the 
required notice is given.  In either case, the IJ must be removed no later than 23 days 
from the last day of the survey or the provider agreement will be terminated. 
 
In addition, when IJ is identified on the current survey, (whatever Health and/or LSC 
survey is currently being performed, e.g., standard, revisit, or complaint), that 
resulted in serious injury, harm, impairment or death a CMP must be imposed. 
 
For IJ citations where there is no resultant serious injury, harm, impairment or 
death but the likelihood is present, a remedy must be imposed; however, the 
CMS Location may select any remedy that best achieves the purpose of 
achieving and sustaining compliance and address various levels of 
noncompliance.  See Section 7400 which describes available remedies. 
 
When IJ is identified, the facility must submit an allegation that the IJ has been removed.  
This allegation must include a plan of sufficient detail to demonstrate how and when the 
IJ has been removed.   
 
A plan of correction for the deficiencies should be deferred until a revisit is conducted to  verify the removal of the IJ.  Documentation resulting from the revisit must be completed 
indicating whether the IJ was removed and deficiencies corrected (Form CMS-2567B), or 
that the IJ was removed but compliance had not been achieved (Form CMS-2567).  When 
a new Form CMS-2567 is necessary, it should be written with evidence that supports the 
remaining noncompliance. 
 
NOTE:  In order for a 23-day termination to be stopped, the IJ must be removed, even 
if the underlying deficiencies have not been fully corrected.  Waiting for acceptable 
plans of correction can result in undue delay in determining removal of IJ.  Therefore, 
plan of corrections should be deferred until the IJ is removed.  
 
If the facility alleges that the IJ is removed and a revisit verifies that it has been removed 
but the facility is still not in substantial compliance, use the non-IJ process, which 
requires a plan of correction for all citations.  Waiting for the complete statement of 
deficiencies (Form CMS-2567) and the facilitys plan of correction for the non-IJ 
deficiencies can result in undue delay in determining removal of IJ.  Therefore, a 
Statement of Deficiencies (Form CMS-2567) and a facilitys plan of correction for the 
non-IJ deficiencies may be deferred until the survey agency verifies the IJ is removed. 
 
In addition, whenever a facility has deficiencies that constitute both IJ and substandard 
quality of care (SQC) (as defined in 42 CFR 488.301), the survey agency must notify 
the attending physician of each resident found to have received SQC as well as the State 
board responsible for licensing the facilitys administrator.  Notify physicians and the 
administrator licensing board in accordance with 7320. 
 
7309 - Key Dates When Immediate Jeopardy (IJ) Exists 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
NOTE: These timelines apply whether the survey was conducted by a State Survey 
Agency, CMS Location or a CMS contractor. 
 
 
7309.1 - 2nd Calendar Day 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
No later than two (2) calendar days (one of which must be a working day) 
following the last date of the survey which identified the IJ the survey entity 
must notify in writing; 
 
  The CMS Location  and the State Medicaid Agency of its findings by e-
mail or facsimile (FAX): and, 
  The facility of the IJ findings and that the survey entity is recommending 
to the CMS Location and the State Medicaid Agency that the provider 
agreement be terminated and that a Civil Money Penalty (CMP) or other 
remedies may be imposed.  A temporary manager may be imposed in 
lieu of or in addition to termination (see 488.410)       
This notice may also serve as the formal notice from the State Survey Agency for 
imposition of any category 1 remedy or denial of payment for new admissions remedy 
when authorized by the CMS Location and/or the State Medicaid Agency.  This notice 
must also include the facilitys right to informal dispute resolution (IDR) or an 
independent informal dispute resolution (IIDR) and to a formal appeal of the 
noncompliance. 
 
NOTE: this written notice is separate from the survey entitys responsibility to 
inform the facility onsite during the survey of the IJ findings and their 
responsibility to provide a written allegation of removal of the IJ with sufficient 
detailed information to demonstrate how and when the IJ was removed.  
    7309.2 - 5th -21st Calendar Day 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Except when formal notice of remedies is provided by the State Survey Agency, as 
authorized by CMS and/or the State Medicaid Agency, the CMS Location and/or the 
State Medicaid Agency issues a formal notification of remedies to the facility.  In 
addition, the notice should include the facilitys right to a formal appeal of the 
noncompliance which led to the temporary management remedy, termination, or any 
other enforcement actions (except State monitoring).  For the temporary management 
remedy, the notice will advise the facility of the conditions of temporary management 
and that failure to relinquish control to the temporary manager will result in termination.  
The general public is also given notice of the impending termination. 
.  The general public is also given notice of the impending termination. 
 
7309.3 - No Later Than 10th Business Day 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
If the survey entity verifies that the IJ has been removed, then it must send the 
Statement of Deficiencies (Form CMS-2567) to the facility. 
 
NOTE: The facility must submit a written allegation of removal of the IJ with sufficient 
detailed information to demonstrate how and when the IJ was removed.  If a PoC is to 
be submitted, it must be received no later than 10 calendar days after the facility 
receives their Statement of Deficiencies (Form CMS-2567). 
 
7309.4 - By 23rd Calendar Day 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Termination takes effect unless the IJ has been removed.  
 
7310 - Immediate Jeopardy (IJ) Does Not Exist 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
These procedures incorporate 1819(h)(2)(A)(ii), 1919(h)(1)(B), and 1919(h)(3)(B)(ii) 
of the Act, as well as implementing regulations in 42 CFR 488.412. 
 
The broad array of remedies varies in form and severity in recognition of the fact that 
there can be variations in impact posed by each violation of participation requirements.  
Therefore, while provider agreement terminations are authorized in non-immediate 
jeopardy cases, it is not generally necessary or desirable to choose that remedy when 
substantial compliance may be achieved rapidly through imposition of one or more 
alternative remedies. 
 
When the surveying entity finds that a facilitys deficiencies do not pose IJ to resident 
health or safety, but the facility is not in substantial compliance, the surveying entity may 
recommend that the enforcing entity either terminate the facilitys provider agreement, or  impose alternative remedies, or do both.  The State may also provide formal notice of 
imposition and rescission of category 1 remedies and/or denial of payment for new 
admissions, as authorized by CMS and/or the State Medicaid Agency.  The action may be 
taken immediately, or the facility may be given an opportunity to correct, as described in 
7304.  
 
When the CMS Regional Office finds through a validation survey or review of the States 
findings that any of the facilitys deficiencies do not pose IJ to resident health or safety 
but the facility is not in substantial compliance, the CMS Regional Office must, as 
appropriate, take action itself to terminate the facilitys provider agreement (or stop 
Federal financial participation), or impose alternative remedies instead of terminating the 
provider agreement, or both; or direct the State Medicaid Agency to terminate the 
facilitys Medicaid provider agreement.  The authority for CMS to take enforcement 
action for any nursing facility, when CMS finds the nursing facility to be out of 
compliance, is at 1919(h)(3)(A) and (B). 
 
7312 - Considerations Affecting Enforcement Recommendation to 
Impose Remedies When Immediate Jeopardy Does Not Exist 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If the States recommendation is that alternative remedies be imposed instead of 
terminating the provider agreement, the criteria that permits a Medicare facility (for 
Medicare) and the State (for Medicaid) to receive continued Federal payment must be 
met.  However, the provision requiring the States agreement to repay for Medicaid was 
deleted by the Balanced Budget Act of 1997.  The criteria are codified in 
42 CFR 488.450 and are included in 7600.  If any one of the criteria is not met, the 
recommendation to impose alternative remedies instead of termination cannot be made.  
When alternative remedies are not preferable as the sole enforcement response, the 
enforcing entity can either impose remedies in addition to terminating the provider 
agreement, or only terminate the provider agreement.  However, at a minimum, the 
mandatory denial of payment for all new admissions remedy must be imposed and 
effective within 3 months from the last date of the survey if the facility has not achieved 
substantial compliance.  (See 42 CFR 488.417 and 7506 for guidance about when and 
how to impose this mandatory remedy.) 
 
The State recommends, (and/or as appropriate, imposes or gives notice about certain 
remedies as authorized by CMS or the State Medicaid Agency), termination, or 
termination plus alternative remedies, or alternative remedies instead of termination.  
(See 7600 for considering alternative remedies instead of termination.) 
 
7313 - Procedures for Recommending Enforcement Remedies When 
Immediate Jeopardy(IJ) Does Not Exist 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Once noncompliance is identified, the surveying entity must first determine whether to 
immediately impose remedies in accordance with the criteria in 7304.1 or give the  facility an opportunity to correct its deficiencies before remedies are imposed. 
 
7313.1 - Facilities Given an Opportunity to Correct Deficiencies 
prior to the Immediate Imposition of Federal Remedies 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
A facility may be permitted to correct its deficiencies and delay the imposition of 
remedies only when the criteria outlined in 7304.1 of this chapter are not met.  
Facilities must submit an acceptable plan of correction for its deficiencies (other than 
Scope/Severity level A). 
 
7314 - Special Procedures for Recommending and Providing Notice of 
Imposition and Rescission of Category 1 Remedies and Denial of 
Payment for New Admissions Remedy 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Before the State provides formal notice of the imposition of a category 1 remedy and/or 
denial of payment for new admissions, as authorized by CMS and/or the State Medicaid 
Agency, the State notifies the CMS Location and the State Medicaid Agency of its 
proposed action.   
 
The notice to the CMS Location or State Medicaid Agency can be electronic or written.  
If the CMS Location or State Medicaid Agency has not indicated its disapproval of the 
category 1 remedies and/or denial of payment for new admissions within 2 calendar days 
(at least one of which is a work day) of the date of notice, the State sends a letter to the 
facility providing notice as authorized by CMS and/or the State Medicaid Agency, (as 
appropriate) that a category 1 remedy and/or denial of payment for new admissions is 
being imposed.  (See 7311 for CMSs authority to take enforcement action against any 
nursing facility).  A State official signs the letter on behalf of the CMS Location and/or 
State Medicaid Agency.  A copy of the letter is sent to the CMS Location and State 
Medicaid Agency.  The CMS Location notifies the Medicare Area Contractor and the 
State Medicaid Agency of the denial of payment for new Medicare and/or Medicaid 
admissions.  Formal notice of the rescission of these remedies may also be provided by 
the State, as authorized by the CMS Location and/or the State Medicaid Agency.  (See 
also 7311 and 7506.1.) 
 
7315 - Disagreements About Remedies When Immediate Jeopardy Does 
Not Exist 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Disagreements between the CMS Location and the State Medicaid Agency about the 
application of remedies, including the remedy of termination and its timing, should be 
resolved in accordance with 42 CFR 488.452 and 7807.  If the CMS Location disagrees 
with the States recommendation, the CMS Location will contact the State Medicaid 
Agency and the State to resolve the differences.   
7316 - Key Dates When Immediate Jeopardy Does Not Exist 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7316.1 - Required Actions When There Is an Opportunity to Correct 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
1.  By no later than the 10th working day after the last day of the survey, the State 
must forward to the facility Form CMS-2567, and an initial letter and other 
documents and information in accordance with 7305.1.1. 
 
2.  By the 10th calendar day after the facility receives Form CMS-2567, it submits its 
plan of correction to the State addressing all of the required elements as described 
in 7304. 
 
3.  If the facility does not submit an acceptable plan of correction by the 10th 
calendar day after it receives the Form CMS-2567, the State notifies the facility 
that it is recommending to the CMS Location and/or the State Medicaid Agency 
that remedies be imposed effective as soon as notice requirements are met and/or 
to effectuate category 1 remedies and/or denial of payment for new admissions.  
(Civil money penalties may be imposed retroactively, predating the initial notice.) 
 
4.  If the State finds the plan of correction acceptable, it notifies the facility by phone,  
e-mail, etc. The State sends written notice to the facility if the plan of correction is 
unacceptable.  The letter also states recommended remedies if substantial 
compliance is not verified in accordance with the instructions for verifying 
compliance in 7317.  (See 7305 for notice requirements.) 
 
5.  The CMS Location and/or State Medicaid Agency may provide formal notice of 
imposition of category 1 remedies and/or denial of payment for new admissions. 
 
6.  The State may provide formal notice as authorized by the CMS Location and/or 
State Medicaid Agency, of imposition of category 1 remedies and/or denial of 
payment for new admissions, if applicable.  However, such formal notice of 
imposition of denial of payment for new admissions will most often be provided 
in the revisit letter rather than in the initial letter.  (See also 7301, 7305.1, 
7311, 7313.2,7314, and 7506.1) 
 
7.  Except in the case of category 1 remedies and denial of payment for new 
admissions, if applicable, the CMS Location and State Medicaid Agency must 
provide notice before enforcement actions are imposed and effective in 
accordance with 7305. 
 
8.  If the State provides formal notice of imposition of a category 1 remedy and/or 
denial of payment for new admissions, if applicable, it notifies the CMS Location  and/or the State Medicaid Agency 2 calendar days (at least one of which is a 
working day) before notice is sent to the facility. 
 
9.  If denial of payment for new admissions has not already been imposed and the 
facility is still out of compliance at the 3rd month after the last day of the survey, 
the CMS Location and/or State Medicaid Agency must impose a mandatory denial 
of payment for all new admissions to be effective 3 months after the last day of 
the survey.  (See 7506.)  Formal notice of this remedy may have already been 
provided in the States initial letter to the facility (see 7305). 
 
10. No later than the 6th month after the last day of the survey, termination is 
effective, or if an agreement to repay is signed for Medicare, Federal funding is 
stopped.  (See 7600.) 
 
11. The facility may request informal dispute resolution during the same 10 calendar 
days it has for submitting its plan of correction to the surveying entity; and 
 
7316.2 - Required Actions When There Is No Opportunity to Correct 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
1.  By no later than 10 working days after the last day of the survey, the State must 
forward to the facility Form CMS-2567, an initial letter, and other documents and 
information in accordance with 7305.1.2.  This letter may also provide official 
notice for imposition of category 1 remedies and/or denial of payment for new 
admissions by the State, as authorized by CMS and/or the State Medicaid Agency.  
(See 7305.) 
 
2.  If the State provides formal notice of imposition of a category 1 remedy and/or 
denial of payment for new admissions, if applicable, it notifies the CMS Location 
and/or the State Medicaid Agency 2 calendar days (at least one of which is a 
working day) before notice is sent to the facility.  (See also 7311, 7314, and 
7506.1) 
 
3.  Within the same 10 working days and when the State is not imposing any 
remedies, as authorized by CMS and/or the State Medicaid Agency, the State 
forwards notice to the CMS Location and/or State Medicaid Agency of its 
recommendation(s) for immediate remedies. 
 
4.  The CMS Location or State Medicaid Agency must provide formal notice of the 
remedies imposed unless official notice has already been provided by the State, as 
authorized by CMS and/or the State Medicaid Agency. 
 
5.  By the 10th calendar day after the facility receives Form CMS-2567, it submits its 
plan of correction to the State addressing all of the core elements as described in 
7304. 
  6.  The State may provide notice, as authorized by the CMS Location or State 
Medicaid Agency, of imposition of category 1 remedies and/or denial of payment 
for new admissions. 
 
7.  If denial of payment for new admissions has not already been imposed and the 
facility is still out of compliance at the 3rd month after the last day of the survey, 
the CMS Location and/or State Medicaid Agency must impose a mandatory denial 
of payment for new admissions to be effective 3 months after the last day of the 
survey.  (See 7306.) 
 
8.  If the facility has still failed to substantially comply no later than the 6th month 
after the last day of the survey, termination is effective and Federal funding is 
stopped. 
 
9.  Substantial compliance must be verified in accordance with 7317 in order to stop 
any remedy(ies) imposed. 
 
10. The facility may request informal dispute resolution during the same 10 calendar 
day period it has for submitting a plan of correction to the surveying entity. 
 
 
7317 - Acceptable Plan of Correction 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Except in cases of past noncompliance, facilities having deficiencies (other than those at 
scope and severity level A) must submit an acceptable plan of correction.  An acceptable 
plan of correction must: 
 
  Address how corrective action will be accomplished for those residents found to 
have been affected by the deficient practice; 
  Address how the facility will identify other residents having the potential to be 
affected by the same deficient practice; 
  Address what measures will be put into place or systemic changes made to ensure 
that the deficient practice will not recur;  
  Indicate how the facility plans to monitor its performance to make sure that 
solutions are sustained; and 
  Include dates when corrective action will be completed.  The corrective action 
completion dates must be acceptable to the State.  If the plan of correction is 
unacceptable for any reason, the State will notify the facility in writing.  If the 
plan of correction is acceptable, the State will notify the facility by phone, e-mail, 
etc.  Facilities should be cautioned that they are ultimately accountable for their 
own compliance, and that responsibility is not alleviated in cases where 
notification about the acceptability of their plan of correction is not made timely.  
  The plan of correction serves as the facilitys allegation of compliance and, without it, 
CMS and/or the State have no basis on which to verify compliance.  A plan of correction 
must be submitted within 10 calendar days from the date the facility receives its Form 
CMS-2567.  If an acceptable plan of correction is not received within this timeframe, the 
State notifies the facility that it is recommending to the RO and/or the State Medicaid 
Agency that remedies be imposed effective when notice requirements are met.  The 
requirement for a plan of correction is in 42 CFR 488.402(d).  Further, 42 CFR 
488.456(b)(ii) requires CMS or the State to terminate the provider agreement of a facility 
that does not submit an acceptable plan of correction. 
 
A facility is not required to provide a plan of correction for a deficiency cited as past 
noncompliance because that deficiency is corrected at the time it is cited; however, the 
survey team must document the facilitys corrective actions on Form CMS-2567. 
 
7317.1 - Verifying Facility Compliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
While the plan of correction serves as the facilitys allegation of compliance in non-
immediate jeopardy cases, substantial compliance cannot be certified and any remedies 
imposed cannot be lifted until facility compliance has been verified.  The chart that 
follows in this section provides a course of action for certifying compliance based on the 
seriousness of the noncompliance and the number of revisits that have already occurred.  
It represents a continuum, ranging from accepting the latest correction date on the 
facilitys approved plan of correction as the date of compliance without an onsite revisit, 
to conducting an onsite revisit to establish that date.  The chart also indicates the 
circumstances under which revisits must occur and remedies must be imposed, as well as 
provides policy for conducting revisits, lifting remedies, and certifying compliance.  It is 
important to remember that:  revisits may be conducted anytime for any level of 
noncompliance subject to the allowed number of revisits (see 7317.2, below); remedies 
may be imposed anytime for any level of noncompliance; and revisits are not assured 
before termination can occur.  Also, it should be noted that this guidance applies to 
prospective, as well as currently participating, facilities. 
 
7317.2 - Revisits 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
While both paper reviews and onsite reviews are considered to be revisits, only onsite 
revisits are considered in the revisit count for purposes of the revisit policy.  
 
1.  Mandatory onsite revisits.   An onsite revisit is required when a facilitys: 
 
  beginning survey finds deficiencies that constitute substandard quality of 
care, harm, or immediate jeopardy.  Onsite revisits must continue for these 
deficiencies even if they lessen to lower levels of noncompliance.  
However, if the first onsite revisit finds substantial compliance with these 
tags, no continued onsite revisits are necessary for any other tags that are  cited at or below level F (no substandard quality of care). 
 
  first onsite revisit finds deficiencies that constitute substandard quality of 
care, harm, or immediate jeopardy.  Onsite revisits must continue for these 
deficiencies even if they lessen to lower levels of noncompliance. 
 
  second onsite revisit finds any noncompliance. 
 
The State will seek CMS regional office approval for a third onsite revisit or recommend 
to the regional office that the facility be terminated.  
 
2.  No guarantee of revisit.  A facility is not entitled to any revisits; revisits are 
performed in accordance with guidelines provided in this section and at the 
discretion of CMS or the State.  When conducted, however, one revisit will 
normally be conducted after a survey which found noncompliance and another 
before the expiration of the 6-month period by which a facility must be in 
substantial compliance to avoid termination of its provider agreement.  
Authorization must be obtained from the regional office for more than two onsite 
revisits for Medicare-only and dually participating facilities. 
 
The following chart provides the course of action for certifying substantial 
compliance and for conducting onsite revisits:  Revisit/Date of Compliance Policy 
 
Revisit #  Substantial Compliance  Old deficiencies corrected but  Old deficiencies corrected  Noncompliance  Any noncompliance 
    continuing noncompliance at F(no  but continuing  continues   
SQC) or below  noncompliance at F(SQC),     
harm or IJ 
1st revisit  Compliance is certified as of  1.  A 2nd onsite revisit is  1. A 2nd onsite revisit is  1. A 2nd onsite revisit is   
the latest correction date on the  discretionary if acceptable evidence  required.  required. 
approved PoC, unless it is  is provided.      
determined that either    2. Acceptable evidence is  2. Acceptable evidence 
correction actually occurred  When evidence is accepted with no  required if the facility wants  is required if the facility 
between the latest correction  2nd onsite revisit, compliance is  a date earlier than that of the  wants a date earlier than 
date on the PoC and the date of  certified as of the date confirmed by  2nd onsite revisit to be  that of the 2nd onsite 
the 1st onsite revisit, or  the evidence.  considered for the  revisit to be considered 
correction occurred sooner than    compliance date.  as the compliance date.  
the latest correction date on the  2. When a 2nd onsite revisit is     
PoC.  conducted, acceptable evidence is   
required if the facility wants a date 
earlier than that of the 2nd onsite 
revisit to be considered for the 
compliance date. 
2ndrevisit  Compliance is certified as of        1.  A remedy must be 
the date of the 2nd onsite revisit    imposed if not already 
or the date confirmed by the  imposed. 
acceptable evidence, whichever   
is sooner.  2. Either conduct a 3rd 
onsite revisit or proceed 
to termination.  
A 3rd REVISIT IS NOT ASSURED AND MUST BE APPROVED BY THE RO 
3rd revisit   Compliance is certified as of        Proceed to 
the date of the 3rd onsite  termination. 
revisit. 
Examples of acceptable evidence may include, but are not limited to:   Givens: 
   
  An invoice or receipt verifying purchases, repairs, etc.    An approved PoC is required whenever there is noncompliance; 
  Sign-in sheets verifying attendance of staff at in-services training.    Remedies can be imposed anytime for any level of noncompliance; 
  Interviews with more than 1 training participant about training.    Onsite revisits can be conducted anytime for any level of noncompliance; 
  Contact with resident council, e.g., when dignity issues are involved.    Revisit #  Substantial Compliance  Old deficiencies corrected but  Old deficiencies corrected  Noncompliance  Any noncompliance 
    continuing noncompliance at F(no  but continuing  continues   
SQC) or below  noncompliance at F(SQC),     
harm or IJ 
   
   
 
   
   
3.  Purpose of revisit.  The purpose of a revisit is to determine whether 
substantial compliance has been achieved. 
 
4.  Number of onsite revisits.  Two onsite revisits are permitted, at the States 
discretion, without prior approval from the regional office; a third onsite revisit 
may be approved only at the discretion of the regional office.  Regional offices 
are limited to approving only this one additional onsite revisit.  This policy 
applies to Medicare-only, dually participating, and State-operated facilities.  For 
Medicaid-only facilities, CMS can neither limit the number of revisits nor require 
States to obtain approval from the regional office or the State Medicaid Agency 
for a third onsite revisit; however, States should follow this policy so that the 
Medicare and Medicaid programs are run consistently.  
 
The effect of specific survey activities on the onsite revisit count follows: 
 
  Complaint surveys.  Initial complaint investigation visits, whether 
substantiated or not, are not included in the onsite revisit count.  However, 
when the complaint survey is conducted at the same time as the onsite 
revisit, the revisit is included in the onsite revisit count.  And, although the 
complaint survey itself is not considered a revisit, any revisits associated 
with it count toward the onsite revisit count.  This also applies to Federal 
complaint guidelines. 
 
When a complaint is received and the complaint survey is conducted after 
the third onsite revisit but before the 6-month termination date, any 
deficiencies identified by the complaint survey should be cited and would 
provide additional evidence in support of the termination action.  Since 
three onsite revisits have already been conducted, another onsite revisit 
cannot be conducted without consultation with the regional office and 
central office.  Situations such as this should be discussed with the 
regional office since it may have already sent a termination letter.  In 
addition, States should not use this complaint survey as an opportunity to 
determine if deficiencies from the third onsite revisit have been corrected. 
 
  Life safety code surveys.  When the onsite revisit is for the sole purpose 
of either the health survey or the life safety code survey, but not both, 
there are separate revisit counts toward each survey, regardless of the 
timing of the two surveys and regardless of whether the same entity is 
performing the surveys and onsite revisits.  When the onsite revisit is for 
both the health survey and the life safety code survey, both surveys are 
covered by the same onsite revisit count.   
 
  Visits to determine removal of immediate jeopardy.  An onsite visit to 
determine if immediate jeopardy has been removed will be included in the 
onsite revisit count.  (See 7308 for documentation requirements.) 
   
  Visits to special focus facilities.  The onsite revisit policy applies to 
Special Focus Facilities as it does to all other facilities, but the extra drop-
by visits to these facilities do not count against the onsite revisit count. 
 
  State monitoring.  Monitoring visits are not included in the onsite revisit 
count because no survey is being performed.  State monitoring is a remedy 
to oversee the correction of cited deficiencies and ensure that residents are 
protected from harm; onsite revisits are onsite visits specifically intended 
to verify correction of deficiencies cited in a previous survey.  
 
5.  Timing of revisit.  When conducted, onsite revisits occur any time between 
the last correction date on the plan of correction and the 60th day from the survey 
date to confirm that the facility is in substantial compliance and, in certain cases, 
has the ability to remain in substantial compliance.  Conducting a revisit before 
the 60th day allows time for a notice of a mandatory denial of payment for new 
admissions at the 3rd month, if necessary.  If the facility is found to be in 
substantial compliance, the State will certify compliance. 
 
6.  Correction of level A, B, and C deficiencies.  While facilities are expected to 
correct deficiencies at levels A, B, and C, deficiencies at these levels are within 
the substantial compliance range and, therefore, need not be reviewed for 
correction during subsequent revisits within the same noncompliance cycle. 
 
7.  Revisits to surveys for which substandard quality of care, harm, and 
immediate jeopardy are cited.  When substandard quality of care, actual harm, 
or immediate jeopardy is cited. onsite revisits must continue for these deficiencies 
even if they lessen to lower levels of noncompliance.  However, if the first onsite 
revisit determines that the facility has achieved substantial compliance with those 
affected tags, no continued onsite revisits are necessary for any other tags that are 
cited at or below level F (no substandard quality of care).   
 
8.  New Owner.  If a new operator assumes the existing provider agreement, he or 
she is responsible for assuring that corrections are made within the revisit policy. 
 
7317.3 - Noncompliance Cycles 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A noncompliance cycle begins with a recertification, complaint or temporary waiver 
revisit survey that finds noncompliance and ends when substantial compliance is 
achieved or the facility is terminated (or voluntarily terminates) from the Medicare or 
Medicaid program.  (See also 7001.)  The noncompliance cycle cannot exceed 6 
months. Once a remedy is imposed, it continues until the facility is in substantial 
compliance (and in some cases, until it can demonstrate that it can remain in substantial 
compliance), or is terminated from the programs. 
 
  7319 - Procedures for Certifying Compliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7319.1 - Non-State Operated Skilled Nursing Facilities and Nursing 
Facilities or Dually Participating Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
1.  The State conducts the survey and certifies compliance. 
 
2.  The State sends the facility Form CMS-2567 and if applicable, the Notice of 
Isolated Deficiencies Which Cause No Actual Harm With the Potential for 
Minimal Harm (Form A), within 10 working days of the last day of survey. 
 
3.  If the facility is in substantial compliance, but deficiencies constitute a pattern or 
widespread findings causing no actual harm and potential for only minimal harm, 
the State instructs the facility to submit a plan of correction to the States office.  
(This must be submitted within 10 calendar days after the facility has received its 
Statement of Deficiencies.)  There is no requirement for the State to conduct a 
revisit to verify correction, but the facility is expected to comply with its plan of 
correction. 
 
4.  If the facility is in substantial compliance, but has deficiencies that are isolated 
with no actual harm and potential for only minimal harm, the State records the 
deficiencies on the Notice of Isolated Deficiencies Which Cause No Actual Harm 
With the Potential for Minimal Harm (Form A).  A plan of correction is not 
required for these deficiencies, but facilities are expected to correct them. 
 
5.  The State enters the certification information into the Certification and 
Transmittal screen of the certification tab in the Automated Survey Processing 
Environment system (ASPEN).  This can occur as soon as substantial compliance 
is achieved.   
 
7319.2 - State-Operated Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
1.  The State conducts the survey and documents its findings on Form CMS-2567 and if 
applicable, on the Notice of Isolated Deficiencies Which Cause No Actual Harm 
With the Potential for Minimal Harm (Form A). 
 
2.  The State forwards its survey findings to the regional office within 10 working days 
of the last day of the survey. 
 
3.  If the facility has deficiencies that are widespread or constitute a pattern and which 
cause no actual harm and potential for only minimal harm, the regional office 
instructs the facility to submit its plan of correction to the regional office.  The plan of 
  correction must be submitted within 10 calendar days after the facility has received its 
Statement of Deficiencies. 
 
4.  The regional office enters the certification information into the Certification and 
Transmittal screen of the certification tab in the Automated Survey Processing 
Environment system (ASPEN). 
 
7320 - Action When There is Substandard Quality of Care 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(g)(5)(C) and 1919(g)(5)(C) of the Act and 42 CFR 488.325 require that 
when a facility is found to have provided substandard quality of care, notification of that 
finding must be provided to the attending physician of each resident found to have 
received such care as well as to the State board responsible for licensing the facilitys 
administrator.  The facilitys ability to provide a nurse aide training and competency 
evaluation program must also be prohibited for 2 years from the date of the finding of 
substandard quality of care.  (See 7303 for related appeal rights.) 
 
7320.1 - Repeated Substandard Quality of Care 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7320.1.1 - Action to Be Taken When a Facility Is Found to Have 
Provided Substandard Quality of Care on Last Three Standard Surveys 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(h)(2)(E) and 1919(h)(2)(D) of the Act and 42 CFR 488.414 require that 
when a facility has been found to have provided substandard quality of care (as defined in 
42 CFR 488.301) on the last three consecutive standard surveys, CMS or the State 
Medicaid Agency, as appropriate, must, regardless of other remedies: 
 
  Deny payment for all new admissions no later than 3 months from the last day of 
the third consecutive survey in accordance with 7506;  
 
  Impose State monitoring in accordance with 7504; and 
 
  Provide notification of the finding of substandard quality of care to the attending 
physician of each resident found to have received such care, as well as to the State 
board responsible for licensing the facilitys administrator.  These notifications 
occur whenever there is a finding of substandard quality of care.  
 
7320.1.2 - Factors Which May or May Not Affect a Determination of 
Repeated Substandard Quality of Care 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  The fact that a facility has had any change in its program participation will not affect this 
determination.  In other words, any standard survey completed for Medicare, Medicaid, 
or both, will be considered in this determination.  Termination of a facility would allow 
the count of repeated substandard quality of care surveys to start over.  A change of 
facility ownership would not allow the count to start over unless the new owner can 
demonstrate to the States satisfaction that the poor past performance is no longer a factor 
due to the change of ownership. 
 
7320.1.3 - Notification Requirements 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Notification to the facility by CMS, or the State Medicaid Agency, or the State, as 
appropriate, would be in accordance with 42 CFR 488.402.  The notice will inform the 
facility that the remedies will continue until the facility has demonstrated that it is in 
substantial compliance with requirements and that it will remain in substantial 
compliance with the requirements.  The facility will also be notified that it cannot avoid 
the imposition of remedies or the obligation to demonstrate that it will remain in 
compliance when it either alleges correction of the deficiencies cited in the most recent 
standard survey, or when it achieves compliance before the effective date of the 
remedies.  The finding of repeated substandard quality of care results in the imposition of 
the remedies specified in 7320.1.1 above, regardless of subsequent correction. 
 
7321 - Skilled Nursing Facility or Dually Participating Facility 
Readmission to Medicare or Medicaid Program After Termination 
(Excludes Medicaid-only Nursing Facilities) 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7321.1 - Readmission Criteria 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The general guidelines for readmission can be found in 2016 of this manual. 
 
7321.2 - Reasonable Assurance Concept 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
A Medicare provider terminated under 42 CFR 489.53 may not be reinstated into the 
Medicare program until it has been verified through the reasonable assurance process 
that the provider is capable of achieving and maintaining substantial compliance with all 
applicable participation requirements.  There is no statutory or regulatory requirement 
that States must establish a reasonable assurance period for facilities seeking readmission 
as a Medicaid-only facility.  However, if a terminated facility is readmitted as a nursing 
facility without undergoing a reasonable assurance period, before it can reenter the 
Medicare program as a skilled nursing facility or dually participating facility, it must 
successfully undergo the Medicare reasonable assurance process.  With the exception of 
cases described in 3.2.d of this section, this means that the facility must be found in 
  substantial compliance during one survey at the beginning, and another survey at the end, 
of the reasonable assurance period before it will be readmitted into the Medicare 
program.  The CMS Location has discretion to accept the Medicaid re-entry survey as the 
initial reasonable assurance survey.  If the facility is found not to be in substantial 
compliance during either reasonable assurance survey, then the facilitys application for 
readmission to the Medicare program following termination is denied and the facilitys 
Medicaid provider agreement is subject to termination. 
 
The reasonable assurance decision is an administrative action, not an initial 
determination, and is not subject to the appeals process at 42 CFR 498.3(d)(5). 
 
7321.3 - Reasonable Assurance Surveys 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Two surveys are required to verify that the reason for termination no longer exists and 
that the facility has maintained continued compliance.  While both visits need not be full 
standard surveys, the CMS Location may require, at its discretion, two full surveys be 
done in any particular case.  Typically, if both visits are not full standard surveys, the first 
one is partial and the second a full standard.  The first survey is conducted at the 
beginning of the reasonable assurance period to document compliance with the 
requirements for which there were previous deficiencies.  The second is a full standard 
survey at the end of the reasonable assurance period to document compliance with 
participation requirements. 
 
7321.3.1 - First Visit 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The first visit only needs to determine whether the deficiencies that led to the termination 
have been corrected (i.e., are they now completely removed or at the level of substantial 
compliance).  If, upon looking into compliance in these previously problematic areas, the 
States first visit finds: 
 
a.  there are deficiencies at only levels A, B, or C, then the facility is determined to 
be in substantial compliance.  Therefore, the first visit is acceptable as the first of 
two mandatory surveys.  Any deficiencies found at levels B and C during this 
visit continue to require the submission of a plan of correction.  This visit may be 
the survey conducted for initial Medicaid certification following termination.  If a 
second survey, conducted at the end of the reasonable assurance period, finds that 
the facility has maintained substantial compliance throughout that period, the 
facility may qualify for readmission to the Medicare program. 
 
The CMS Location then sets the reasonable assurance period, after which a 
second (full) survey will be completed.  Sometimes, the CMS Location will 
already have set the reasonable assurance period in the termination notice.  The 
reasonable assurance period can vary from 1 month to 6 months based upon the 
  CMS Locations judgment of the period necessary to ensure that the facility 
demonstrates its ability to maintain compliance. 
 
b.  deficiencies that fall at level D or higher on the first visit, then these findings will 
result in denial for purposes of starting Medicare reasonable assurance even if the 
deficiencies are not in the same regulatory grouping of requirements as those 
deficiencies that led to termination.  The facility does not need to submit a plan of 
correction. 
 
Any subsequent visit that finds substantial compliance may start the reasonable assurance 
period. 
 
Following certification for Medicaid and prior to certification for Medicare, any visit that 
determines noncompliance (either based on a complaint or incident) will result in a 
finding that reasonable assurance has not been demonstrated.  The CMS Location will 
issue a denial notice and start the period of reasonable assurance again when the State 
determines that substantial compliance has been achieved. 
 
7321.3.2 - Second Visit 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The second visit will typically be a full standard survey. 
 
EXCEPTION:  The CMS Location may instruct the State to conduct the full survey 
during the first visit and the partial survey at the second. 
 
a.  If the survey finds no deficiencies or only deficiencies at levels A, B, or C, the 
facility is determined to be in substantial compliance, and the survey is acceptable 
for program participation purposes.  The facility must submit a plan of correction 
for any level B and/or C deficiencies found during the second visit/full standard 
survey. 
 
b.  If the survey finds deficiencies at levels D, E, or F, AND any of those deficiencies 
are in the same regulatory grouping of requirements as the deficiencies that 
caused the facilitys termination, the CMS Location will issue a notice of denial of 
participation. 
 
c.  If the survey finds deficiencies that fall at levels D, E, or F, and the survey finds 
substandard quality of care, the CMS Location will issue a notice of denial of 
participation. 
 
d.  If the survey finds deficiencies that fall at levels D, E, or F that do not constitute 
substandard quality of care and are not in the same regulatory grouping as the 
deficiencies that caused termination, the CMS Location may accept the second 
visit/full standard survey for participation based upon receipt of an acceptable 
plan of correction for all deficiencies above level A, and verification of 
  substantial compliance through an onsite visit.  While the plan of correction 
submittal date does not determine the effective date of the agreement, the facility 
must meet this requirement before an agreement can be issued per 42 CFR 
488.402(d). 
 
e.  If the survey finds deficiencies above level F (i.e., those that would constitute 
actual harm or immediate jeopardy), the CMS Location will issue a notice of 
denial of participation. 
 
7321.4 - Effective Date of Provider Agreement 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The controlling regulation for setting the effective date of the provider agreement is 
42 CFR 489.13(b)(3), which provides that the agreement is effective on the date the 
skilled nursing facility is in substantial compliance as defined in 42 CFR 488.301 and, if 
applicable, submits an approvable waiver request.  Regulations at 42 CFR 488.301 define 
substantial compliance as having no deficiencies above level C.  This is paralleled at 42 
CFR 488.330(f). The effective date is the date the second visit/full standard survey (or its 
follow-up visit, where required as indicated below) finds substantial compliance. 
 
1.  If the second visit finds substantial compliance, the effective date is the survey 
completion date, regardless of whether the visit is a full standard or a partial 
survey. 
 
2.  If, on the second visit, CMS accepts a plan of correction for deficiencies at levels 
D, E, or F (without substandard quality of care), the effective date is the date of 
the facilitys attainment of substantial compliance, as verified by a single onsite 
follow-up visit conducted by the State.  This can be a date during the follow-up 
visit or an earlier date that the State can verify. 
 
NOTE:  While the plan of correction submittal date does not determine the 
effective date of the agreement, the facility must meet this requirement 
before an agreement can be issued per 42 CFR 488.402(d).   
 
REASONABLE ASSURANCE EXAMPLES 
 
The following examples are illustrative only and do not purport to control any specific 
case.  Terminations occur for a variety of reasons, and the CMS Location and State will 
need to exercise discretion in each case. 
 
EXAMPLE 1:  NURSING HOME A 
 
Prior History - Nursing Home A is a 150-bed dually participating facility located in a 
rural area.  The facility serves residents with a high acuity level.  It is part of a large 
national, for-profit chain.  The facility had been in the program since 05/01/1978.  
Surveys had revealed condition-level noncompliance in 1987, 1988, 1989, and five level 
  A deficiencies in 1994.  The facility avoided termination each time by correcting its 
deficiencies prior to termination.  The facility underwent a change of ownership on 
06/01/1996.  Since 07/01/1995, the facility had been out of compliance in 1996, 1997, 
and 1998 surveys, but avoided enforcement remedies by attaining compliance before 
remedies were imposed.  The highest level of noncompliance had been at level G during 
this time with no substandard quality of care.  Thus, between the change of ownership in 
1996 and the current cycle of surveys leading to termination, the facilitys compliance 
history had been fair. 
 
The termination - The facility was terminated from both programs on 08/08/1999, for 
failure to attain substantial compliance with program requirements as demonstrated on 
five State visits within a 6-month period.  The survey cycle started with a 02/08/1999 
complaint investigation that revealed 22 deficiencies, with no actual harm, and the 
highest scope and severity of one level F (substandard quality of care due to poor record-
keeping of criminal background checks).  After an opportunity to correct, a revisit and 
another complaint investigation conducted on 04/12/1999 revealed continued 
noncompliance, again with 22 deficiencies, many of which were the same deficiencies 
(again, no harm).  A second revisit on 06/16/1999 revealed continued noncompliance 
with 10 deficiencies, two of which were at level G.  The third revisit on 07/26/1999 was 
also a standard survey, which revealed 28 deficiencies, with no harm and no substandard 
quality of care.   At this point the organization infused the facility with many additional 
resources and a decision was made to revisit a final time.  The final revisit was conducted 
on 08/10/1999 and found only three deficiencies at the noncompliance level (two level 
Ds and one level E).  Termination was effective 08/08/1999 since the facility was not in 
substantial compliance within 6 months. 
 
Reasonable Assurance Decision - The facility first applied for Medicaid-only 
recertification.  Medicare certification was not initially sought due to the delay in Form 
CMS-855 review by the fiscal intermediary, the prohibition on the conduct of a Medicare 
survey pending Form CMS-855 clearance, and the absence of a reasonable assurance 
requirement for re-entry into the Medicaid program.  Since this would be the initial 
certification survey for Medicaid, the tasks of both the standard and extended surveys are 
required, as well as confirming compliance with all regulatory requirements.  The 
Medicaid re-entry survey was conducted on 09/11/1999, with only two level B 
deficiencies.  The facility was certified for Medicaid effective 09/11/1999, the date of 
receipt of an acceptable plan of correction.  On 09/12/1999, the facility applied for re-
entry into the Medicare program.  After Form CMS-855 clearance by the fiscal 
intermediary on 11/15/1999, the CMS Location determined that, based on the initial 
Medicaid survey, the cause for termination had been removed.  The CMS Location 
established a reasonable assurance period of 90 days from the date of the Medicaid 
survey on 09/11/1999.  Thus, the second reasonable assurance survey, a standard survey, 
would be conducted after 12/11/1999. 
 
Rationale - A 90-day reasonable assurance period was chosen due to the fact that the 
facility remained out of compliance, having many of the same deficiencies over a 6-
month period.  A longer period was not deemed necessary in consideration of the 
  following:  
 
1.   The clean Medicaid re-entry survey, even though residents continued with a 
high acuity level;  
 
2.   A fair history of compliance since the change of ownership;  
 
3.   The State was late in conducting the annual survey until 2 weeks before the 
termination date, yet the facility removed all but three deficiencies by the 
termination date;  
 
4.   The lack of actual harm on three of five visits, with only three deficiencies at a 
level G over the entire 6-month period despite the fact that the facility 
provided services to residents with a very high acuity level; and 
 
5.   The lack of additional, satisfactory Medicare beds in the area, with the closest 
facility with vacancies determined to be a problem chain facility in 
bankruptcy  
 
EXAMPLE 2: NURSING HOME B. 
 
Prior History - Nursing Home B is a 100-bed dually participating facility located in a 
major metropolitan area.  It has been in both programs since 1968.  It was previously 
owned and operated by a large national chain until 1992, when a local corporation that 
operates no other nursing homes leased the facility.  In 1989, the facility had two 
Conditions of Participation not met.  In 1990, one level A deficiency (refers to 
participation requirement level designation prior to 07/01/1995) was cited.  From 1991-
1994, several level B deficiencies (refers to participation requirement level designation 
prior to 07/01/1995 were cited on each survey, but no level A findings.  From 07/01/1995 
through 03/20/1998, the facility had no findings of substandard quality of care, with one 
level G, actual harm cited 03/20/1998.  In 1995, the remedy of denial of payment for new 
admissions was initiated, but rescinded because the facility attained compliance prior to 
the effective date of the remedy.  Prior to the 1999 survey cycle, no enforcement actions 
had ever been taken since the facility consistently corrected its deficiencies after an 
opportunity to correct.  
 
The termination - The facility was terminated from both programs effective 07/19/1999 
due to continued noncompliance cited on five surveys/follow-ups over a 6-month period.  
The cycle started with a 01/19/1999 complaint survey that revealed 13 deficiencies, three 
of which were actual harm in Quality of Care.  After an opportunity to correct, the State 
returned on 03/19/1999 and conducted a follow-up and a standard/extended survey that 
revealed 23 deficiencies, with two deficiencies reflecting substandard quality of care.  
Another revisit on 05/19/1999 revealed 19 deficiencies, with an immediate jeopardy.  A 
05/21/1999 monitoring revisit documented removal of the immediate jeopardy, but the 
prior deficiencies remained.  The facility alleged compliance again and the State 
conducted the final revisit on 07/09/1999, with eight cited deficiencies including actual 
  harm and one substandard quality of care.  Upon receipt of the CMS Locations 
termination notice, a chain organization (with no other facilities in the State) alleged to 
have purchased the facility on 03/01/1999 and asked the CMS Location to stop all 
remedies based on the change of ownership.  The CMS Location did not authorize an 
additional revisit beyond the 07/09/1999 follow-up since, despite of the facilitys 
repeated allegations of compliance, subsequent revisits found worsening noncompliance.  
In addition, no change of ownership application had been submitted.  Termination was 
effective on 07/19/1999. 
 
Reasonable Assurance Decision - The facility applied for recertification as a Medicaid-
only facility in order to facilitate re-entry and avoid the delays of the fiscal intermediarys 
Form CMS-855 review.  The Medicaid survey was conducted on 08/20/1999 and 
revealed noncompliance with actual harm with a requirement that was the basis for 
termination.  The facility alleged compliance, and a revisit was conducted on 09/10/1999, 
which revealed compliance.  Medicaid certification was effective 09/10/1999.  Since re-
entry into the Medicaid program on 09/10/1999, the State returned to the facility on 
12/01/1999 to investigate complaints and found noncompliance in one of the regulations 
that led to the previous termination.  The State gave the facility an opportunity to correct 
before imposing remedies.  The facility alleged compliance, and a revisit was conducted 
on 01/19/2000 which found substantial compliance.  
 
The facility applied for Medicare recertification on 03/01/2000. Upon clearance from the 
fiscal intermediaries of Form CMS-855 on 05/05/2000, the CMS Location established a 
reasonable assurance period of 150 days, with two Medicare re-entry surveys required.  
The CMS Location did not accept the Medicaid surveys as a part of its reasonable 
assurance determination.   As a result, the 150-day reasonable assurance period begins 
with a State survey to determine if the cause for termination still exists.  The first 
reasonable assurance survey was conducted on 05/29/2000.  Two level D deficiencies 
were cited, with neither being the cause for termination. The CMS Location accepted that 
survey for establishing the 150-day reasonable assurance period on 05/29/2000.  Thus, 
the State will return after 10/29/2000 to conduct the second reasonable assurance survey 
(standard and extended survey tasks, as well as confirm compliance with all regulatory 
requirements). 
 
Rationale - A 150-day reasonable assurance period was sought because:  
 
1.  The facility had a worsening compliance record during the 6 months leading to 
termination; 
 
2.  Upon re-entry into Medicaid following termination, the facility could not 
maintain compliance; and 
 
3.  The change of ownership was considered in determining the length of the 
reasonable assurance process, but was overshadowed by the facilitys failure to 
maintain compliance following termination.  
  Enforcement Process 
 
7400 - Enforcement Remedies for Skilled Nursing Facilities (SNFs), 
Nursing Facilities (NFs) and Dually Participating Facilities 
(SNFs/NFs) 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Sections 1819(h) and 1919(h) of the Act, as well as 42 CFR 488.404, 488.406, and 
488.408, provide that CMS or the State may impose one or more remedies in addition 
to, or instead of, termination of the provider agreement when the State or CMS finds 
that a facility is out of compliance with federal requirements.  Enforcement 
protocols/procedures are based on the premise that all requirements must be met and 
take on greater or lesser significance depending on the specific circumstances and 
resident outcomes in each facility. 
 
7400.1 - Available Federal Enforcement Remedies 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
In accordance with 42 CFR 488.406, the following remedies are available: 
  Termination of the provider agreement; 
  Temporary management; 
  Denial of payment for all Medicare and/or Medicaid residents by CMS; 
  Denial of payment for all new Medicare and/or Medicaid admissions; 
  Civil money penalties; 
  State monitoring; 
  Transfer of residents; 
  Transfer of residents with closure of facility; 
  Directed plan of correction; 
  Directed in-service training; and 
  Alternative or additional State remedies approved by CMS. 
 
7400.2 - Enforcement Remedies for the State Medicaid Agency 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Regardless of what other remedies the State Medicaid Agency may want to establish in 
addition to the remedy of termination of the provider agreement, it must establish, at a 
minimum, the following statutorily-specified remedies or an approved alternative to 
these specified remedies: 
 
  Temporary management; 
  Denial of payment for all new admissions; 
  Civil money penalties; 
  Transfer of residents; 
  Transfer of residents with closure of facility; and 
    State monitoring. 
 
The State Medicaid Agency may establish additional or alternative remedies if the State 
has been authorized by CMS to do so under its State plan.  Guidance on the review and 
approval (or disapproval) of State Plan amendment requests for alternative or additional 
remedies can be found in 7805. 
 
Whenever a State Medicaid Agencys remedy is unique to its State plan and has been 
approved by CMS, then that remedy may also be imposed by the CMS Location 
against the Medicare provider agreement of a dually participating facility in that State.  
For example, where CMS has approved a States ban on admissions remedy as an 
alternative remedy under the State plan, CMS may impose this remedy but only against 
Medicare and Medicaid residents; only the State can ban the admission of private pay 
residents. 
 
7400.3 - Selection of Remedies 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
To select the appropriate remedy(ies) for a facilitys noncompliance, the seriousness, 
scope and severity of the deficiencies must first be assessed.  The purpose of federal 
remedies is to address a facility responsibility to promptly achieve, sustain and maintain 
compliance with all federal requirements.  In addition to the required enforcement 
action(s), remedies should be selected that will bring about compliance quickly.  While a 
facility is always responsible for all violations of the Medicare and Medicaid 
requirements, when making remedy choices, the CMS RO should consider the extent to 
which the noncompliance is the result of a one-time mistake, larger systemic concerns, 
or an intentional action of disregard for resident health and safety. 
 
7400.3.1 - Matrix for Scope & Severity 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Immediate jeopardy to resident health or safety  J    K    L    
Actual harm that is not immediate  G  H   I   
No actual harm with potential for more than  D  E  F   
minimal harm that is not immediate jeopardy 
No actual harm with potential for minimal harm  A No PoC  B   C  
 
  Isolated  Pattern  Widespread 
 
 Substandard Quality of Care (SQC) is defined in 42 C.F.R. 488.301 as one or more deficiencies 
which constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual 
harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than 
immediate jeopardy, with no actual harm, related to certain participation requirements. 
Substantial` compliance means a level of compliance with the requirements of participation such 
that any identified deficiencies pose no greater risk to resident health or safety than the potential for 
causing minimal harm. Substantial compliance constitutes compliance with participation requirements 
(42 C.F.R. 488.301). 
   
residents. 
 
7400.4 - Other Factors That May Be Considered in Selecting 
Enforcement Remedy Within a Remedy Category 
(Rev. 185, Issued: 11-16-18, Effective: 11-16-18, Implementation: 11-16-18) 
 
Additional factors that may be considered to assist in determining which and/or how 
many remedies to impose within the available remedy categories for levels of 
noncompliance, include but are not limited to: 
  The relationship of one deficiency to other deficiencies; 
  The facilitys prior history of noncompliance in general, and specifically with 
reference to the cited deficiencies; and 
  The likelihood that the selected remedy(ies) will achieve correction and 
continued compliance.   
 
EXAMPLE:  If failure to spend money is the root cause of the facilitys noncompliance, 
then any civil money penalty that is imposed should at least exceed the amount saved by 
the facility by not maintaining compliance. 
 
7400.6 - When To Select Remedy From Specific Remedy Category 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7400.6.1 - Category 1 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Select at least one remedy from category 1 when there: 
 
  are isolated deficiencies that constitute no actual harm with a potential for more 
than minimal harm but not immediate jeopardy; or 
 
  is a pattern of deficiencies that constitutes no actual harm with a potential for 
more than minimal harm but not immediate jeopardy. 
 
EXCEPT when the facility is in substantial compliance, one or more of the remedies in 
category 1 may be applied to any deficiency. 
 
CATEGORY 1 remedies include: 
 
  Directed plan of correction (see 7500); 
 
  State monitoring (see 7504); and 
 
  Directed in-service training (see 7502). 
 
  NOTE:  As an agent of CMS or the State Medicaid Agency, the State may impose one or 
more category 1 remedies, as authorized by CMS or the State Medicaid Agency, 
in accordance with 7314. 
 
7400.6.2 - Category 2 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Select at least one remedy from category 2 when there are: 
 
  Widespread deficiencies that constitute no actual harm with a potential for 
more than minimal harm but not immediate jeopardy; or 
 
  One or more deficiencies (regardless of scope) that constitute actual harm 
that is not immediate jeopardy. 
 
EXCEPT when the facility is in substantial compliance, one or more of the remedies in 
category 2 may be applied to any deficiency. 
 
NOTE: The State Medicaid Agency does not have the statutory authority to impose the 
remedy of denial of payment for all Medicare and/or Medicaid residents. 
 
CATEGORY 2 remedies include: 
  Denial of payment for all new Medicare and/or Medicaid admissions;   
  Denial of payment for all Medicare and/or Medicaid residents, imposed only by 
the CMS Location; 
  Lower range per day civil money penalties 
  Per instance civil money penalties. 
 
7400.6.3 - Selection from Category 3 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Termination or temporary management, or both, must be selected when there are one or 
more deficiencies that constitute immediate jeopardy to resident health or safety.  A civil 
monetary penalty of $3,050 - $10,000 per day or a civil money penalty of $1,000 - 
$10,000 per instance may be imposed in addition to the remedies of termination and/or 
temporary management.  Temporary management is also an option when there are 
widespread deficiencies constituting actual harm that is not immediate jeopardy. 
 
CATEGORY 3 remedies include: 
 
  Temporary management (see 7550); 
 
  Termination (see 7556); 
 
    Civil money penalties of $3,050 - $10,000 per day of noncompliance optional, in 
addition to the remedies of termination and/or temporary management  (See 
7510); or 
 
  Civil money penalties of $1,000 - $10,000 per instance of noncompliance optional 
(see 7510). 
 
NOTE:  Termination may be imposed by the State Medicaid Agency or the 
regional office at any time.  Transfer of residents or transfer of residents 
with closure of the facility will be imposed by the State, as appropriate.  
Although temporary management must be imposed when there is a finding 
of immediate jeopardy (and termination is not sought), temporary 
management may be imposed for lesser levels of noncompliance. 
 
7410 - Life Safety Code Enforcement Guidelines for Skilled Nursing 
Facilities and Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7410.1 - Application of the Enforcement Regulations to Life Safety Code 
Surveys Conducted in Skilled Nursing Facilities and Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Skilled nursing facilities and nursing facilities must meet the requirements at 42 CFR Part 
483, Subpart B, in order to receive payment under Medicare or Medicaid.  To certify a 
skilled nursing facility or nursing facility, complete at least a standard health survey and a 
life safety code survey.  Nursing home enforcement regulations at 42 CFR Part 488, 
Subpart F, are also applicable to life safety code surveys. 
 
The specific requirement for life safety code is found at 42 CFR 483.70(a), Life Safety 
From Fire.  A facility may meet this requirement by complying with the prescriptive 
requirements of the 2000 edition of the life safety code by either waivers of the 
prescriptive requirements or by the Fire Safety Evaluation System. The Fire Safety 
Evaluation System is an equivalent system acceptable to CMS as the authority having 
jurisdiction.  These instructions do not require the completion of a Fire Safety Evaluation 
System (State regulations may restrict its use). 
 
This instruction is applicable when completing Form CMS-2786 - Fire Safety Survey 
Report forms in long-term care facilities. 
 
7410.2 - Life Safety Code Scope and Severity Determination 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
After a life safety code survey is completed, the life safety code surveyor will use the 
following guidance to determine the scope and severity level of the resulting deficiencies 
and the appropriate enforcement action.  The definitions below are similar to those used 
  for health surveys but have been modified, where appropriate, to be applicable to life 
safety code surveys. 
 
7410.2.1 - Scope Levels 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The scope of the deficiency reflects the pervasiveness of the deficiency throughout the 
facility. 
 
Scope is isolated when one or a very limited number of residents or employees is/are 
affected and/or a very limited area or number of locations within the facility are affected. 
 
Scope is a pattern when more than a very limited number of residents or employees are 
affected, and/or the situation has occurred in more than a limited number of locations but 
the locations are not dispersed throughout the facility. 
 
Scope is widespread when the problems causing the deficiency are pervasive (affect 
many locations) throughout the facility and/or represent a systemic failure that affected, 
or has the potential to affect, a large portion or all of the residents or employees. 
 
7410.2.2 - Severity Levels 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The severity of the deficiency reflects the impact the deficiency has on the fire safety of 
the individual.  The four severity levels are defined as follows: 
 
  Level 1 - No actual harm with potential for minimal harm: A deficiency that 
has the potential for causing no more than a minor negative impact on the 
resident(s) or employees. 
 
  Level 2 - No actual harm with a potential for more than minimal harm that is 
not immediate jeopardy: Noncompliance with the requirements of the life safety 
code that results in the potential for no more than minimal physical, mental, 
and/or psychosocial harm to the resident or employee and/or that result in 
minimal discomfort to the residents or employees of the facility, but has the 
potential to result in more than minimal harm that is not immediate jeopardy. 
 
  Level 3 - Actual harm that is not immediate jeopardy: Noncompliance with 
the requirements of the life safety code that results in actual harm to residents or 
employees that is not immediate jeopardy. 
 
  Level 4 - Immediate jeopardy to resident health or safety: Noncompliance 
with the requirements of the life safety code that results in immediate jeopardy to 
resident or employee health or safety in which immediate corrective action is 
necessary because the providers noncompliance with one or more of those life 
safety code requirements has caused, or is likely to cause, serious injury, harm, 
  impairment or death to a resident receiving care in a facility or an employee of the 
facility. 
 
The determination of the scope and severity level when a facility has life safety code 
deficiencies should be based on the impact the life safety code deficiencies have on the 
overall level of life safety in the facility. This is because nearly all life safety code 
requirements deal with safety from harm due to fire.  Each instance of threat in a facility 
can compound attempts at containment, extinguishment, evacuation and/or overall safety.  
Like health deficiencies, for which a scope and severity determination is made for each 
deficiency, the survey agency should make a scope and severity assessment for each life 
safety code deficiency.  
 
This determination should include the likelihood of harm from a fire incident and/or the 
likelihood of the spread of fire in the facility from any one incident.  Consideration in this 
determination may include, but is not limited to, whether the facility is sprinklered or 
unsprinklered, the facilitys construction type and any special fire protection features the 
facility may have. 
 
7410.3 - Survey Coordination and Data Entry 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
States vary in the coordination of their life safety code and health surveys (see 2700.C 
of this manual).  While the two surveys occur simultaneously in some States, they do not 
occur simultaneously in other States.  In order to complete data submissions in a timely 
manner, yet give operational flexibility, input of the life safety code survey data of long-
term care facilities should occur no later than 60 days after the conclusion of the long-
term care survey.  There is no prescribed order of the life safety code survey and health 
surveys; either may precede the other.  Sometimes the same team conducts both the 
health survey and the life safety code survey but it is more typical that different teams are 
responsible for each.  
 
7410.4 - Guidance on Enforcement Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If a facility does not meet the life safety code requirements at 42 CFR 483.70(a), or the 
Fire Safety Evaluation System does not show an equivalent level of fire safety, or no Fire 
safety evaluation system is completed, then the State would determine the scope and 
severity level for the life safety code deficiencies found on the life safety code survey to 
determine the enforcement response.  The pertinent procedures are found at 7301 - 
7400.  If a facility does not meet the requirements at 42 CFR 483.70(a), but shows an 
equivalent level of fire safety after completion of the Fire Safety Evaluation System, then 
the facility is found in substantial compliance. 
 
If, after 3 months from the health survey, the facility has not achieved substantial 
compliance, the denial of payment for new admissions sanction takes effect (see 
42 CFR 488.417). 
   
All deficiencies cited at 42 CFR 483.70(a) that do not constitute immediate jeopardy 
must be corrected within 6 months.  A facilitys failure to achieve substantial compliance 
within 6 months will result in termination.  (Immediate jeopardy deficiencies will result 
in termination within 23 days if the facility does not remove the threat to resident and 
employee safety by then.).  
 
CMSs revisit policy can be found in 7317.  The scope and severity grid can be found in 
7400. 
 
The policies and procedures related to citations of past noncompliance are applicable to 
health (F-tags) and life safety code (K-tags) deficiency citations.  For specific guidance, 
see 7510. 
 
 
7410.5 - Imposition of Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
For standard surveys that begin a noncompliance cycle, the survey agency will follow 
one of two enforcement processes.  Instructions follow about how to determine which 
process to follow. The first process is one in which one enforcement track and set of time 
frames is followed for all deficiencies, regardless of whether they are life safety code 
deficiencies or health deficiencies.  This process is used when the life safety code portion 
and health portion of a standard survey occur together or when the beginning of the 
second (of the two surveys) occurs no more than 7 days from the exit of the first (of the 
two surveys).  Time frames are combined and notices can be combined at the discretion 
of the survey agency.  The second process is one in which two enforcement tracks and 
two sets of time frames are used for deficiencies, i.e., one track for the life safety code 
survey and another track for the health survey.  This process is used when the standard 
survey is the beginning survey, and the life safety code portion and health portion of a 
standard survey occur more than 7 days apart, i.e., the beginning of the second (of the 
two surveys) occurs more than 7 days after the exit of the first (of the two surveys).  Time 
frames and notices are separate for each survey.  Both processes are predicated on the 
assumption that one or more life safety code requirements have not been waived.  
 
7410.6 - Life Safety Code Survey Waiver Guidance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The authority to grant waivers of life safety code provisions is found at 1819(d)(2)(B)(I) 
of the Act and states, The Secretary may waive, for such periods as he deems 
appropriate, specific provisions of such Code which if rigidly applied would result in 
unreasonable hardship upon a facility, but only if such waiver would not adversely affect 
the health and safety of the residents or personnel, ... The facility must document to the 
survey agency that there will be no adverse effect on the health and safety of the residents 
and employees of the facility and that compliance would result in an unreasonable 
hardship on the facility for each specific code provision recommended for a waiver. 
   
The above authority to grant life safety code waivers does not include other Physical 
Environment requirements at 42 CFR 483.70 unless specifically provided for.  Refer to 
7014 for further guidance of non-life safety code requests for waivers or variations.  
 
Waivers are classified into two groups: temporary waivers for a defined time period; and 
continuing waivers that are of indeterminate duration. 
 
7410.6.1 - Temporary Waiver 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A temporary waiver for a defined time period may be considered for a finding for which 
corrective action will take more than 90 days to complete.  If a waiver is granted during 
that time, sanctions will not be imposed under the long-term care enforcement 
regulations.  Examples of the type of corrective action that could warrant a temporary 
waiver could include installation of a sprinkler system or a smoke barrier.  Examples of 
deficiencies that could warrant such waivers include the obstruction of exiting, 
penetrations of smoke barriers, and increased travel distances to exits due to new 
construction or remodeling of a wing of a facility.  In these cases, the waiver would be 
for a reasonable period of time for construction activities, including planning and design. 
The waiver documentation submitted by the facility for approval would include a 
timetable with milestone dates of major activities to correct the deficiency that the 
surveyor could monitor on any subsequent follow-up visits. Extensions and modifications 
of this timetable are not envisioned except under extreme circumstances.  Failure of the 
facility to follow the timetable and the milestones established in the approved temporary 
waiver would subject the facility to the remedies prescribed in the enforcement 
regulations.  If the construction activities are completed within the agreed upon timetable 
and the deficiency is corrected, the existence of the waiver is no longer cited on the Form 
CMS-2567. 
 
When the temporary waiver of life safety code requirements is in effect, the facility 
should have increased fire safety awareness. This increased fire safety awareness may 
include the establishment of interim safety measures such as a fire watch during 
construction, an increased number of fire drills and training of staff at the facility, or 
other measures that would provide an increased measure of fire protection.  
 
7410.6.2 - Continuing Waivers 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Continuing waivers of a specific life safety code requirement are granted when the 
noncompliance cannot be corrected without an unreasonable financial hardship on the 
facility and it does not pose a threat to residents health and safety.  The State cites the 
deficiency on each annual survey although they do not expect it to be corrected by the 
facility due to the existence of the waiver.  Examples of this type of finding may include 
improper corridor width either before or after remodeling, a dead-end corridor longer 
than the specified life safety code length, a specific construction type not met, a 
  noncompliant interior finish type, excessive exit travel distance, or waiting areas open to 
the corridor in a non-sprinklered facility.  CMS grants waivers after an evaluation of the 
specific life safety code deficiency cited and its impact on the life safety of the facility. 
 
A waiver of a life safety code requirement that cannot be corrected and which is likely to 
be cited on each future life safety code survey may be granted for more than 1 year or 
survey interval.  For example, CMS could grant a waiver for a 3-year period after which 
the State reviews it during the life safety code survey; if the waiver is still appropriate, it 
can be extended for another 3-year period.  The survey agency cites the deficiency on the 
annual survey and on the Form CMS-2567 but reviews the waiver only after the 
expiration of the 3-year period.  The plan of correction, submitted by the facility for that 
deficiency, would cite the existence of a waiver.   
 
7410.6.3 - Enforcement and Waived Life Safety Code Requirements 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
For those life safety code requirements that CMS has temporarily waived, the following 
enforcement timetable should be used: 
 
ENFORCEMENT TIMETABLES 
 
Day 1:  The date of the follow-up survey to determine if they have met the 
plan of correction.  This date can be no sooner than the providers 
projected correction date, indicated on an approved plan of correction.  
Even if substantial compliance is not achieved, CMS lifts the waiver on 
this date and the enforcement clock starts.* 
   
3rd Month:  Denial of payment for new admissions is imposed based on life safety 
code noncompliance cited when CMS lifts the waiver, and 
noncompliance continues for a 3-month period after that date. 
   
6th Month  Termination occurs, based on life safety code noncompliance cited 
when CMS lifts the waiver, and noncompliance continues up to a 6-
month period after that date. 
 
*Day 1 can occur a substantial amount of time after the life safety code survey that 
originally triggered the waiver. 
  Remedies 
 
7500 - Directed Plan of Correction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7500.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
These procedures implement the regulatory requirements in 42 CFR 488.424 for 
imposing a directed plan of correction.  A directed plan of correction is one of the 
category 1 remedies the State or CMS Location can select when it finds a facility out of 
compliance with Federal requirements.   
 
7500.2 - Purpose 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The purpose of the directed plan of correction is to achieve correction and continued 
compliance with Federal requirements.   A directed plan of correction is a plan that the 
State or the CMS Location, or the temporary manager (with State or CMS Location 
approval), develops to require a facility to take action within specified time frames. 
 
Achieving compliance is ultimately the facilitys responsibility, whether or not a directed 
plan of correction is followed.  If the facility fails to achieve substantial compliance after 
complying with the directed plan of correction, the State or CMS Location may impose 
another remedy until the facility achieves substantial compliance or is terminated from 
the Medicare or Medicaid programs. 
 
7500.3 - Elements of a Directed Plan of Correction 
A directed plan of correction should address all of the elements required for a facility-
developed plan of correction.  (See 7304) 
 
7500.4 - Causes 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Use of a directed plan of correction should be dependent upon causes identified by the 
State, regional office, or temporary manager.  For example, a directed plan of correction 
may be appropriate when a facilitys heating system fails.  The directed plan of correction 
would specify that the heating system must be repaired or replaced within a specific time 
frame.  If the cause of the noncompliance was a specific structural problem, the facility 
could be directed to implement identified structural repairs such as a new roof, or 
renovations such as replacement of rusted sinks in common bathrooms.  
 
7500.5 - Notice of Imposition of Directed Plan of Correction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  A directed plan of correction may be imposed 15 calendar days after the facility receives 
notice in non-immediate jeopardy situations and 2 calendar days after the facility receives 
notice in immediate jeopardy situations.  The date the directed plan of correction is 
imposed does not mean that all corrections must be completed by that date.  
 
7502 - Directed In-Service Training  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7502.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
These instructions implement 42 CFR 488.425.  Directed in-service training is one of the 
remedies the State or regional office can select when it finds a facility out of compliance 
with Federal requirements. 
 
7502.2 - Purpose 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Directed in-service training is a remedy that may be used when the State, CMS, or the 
temporary manager believe that education is likely to correct the deficiencies and help the 
facility achieve substantial compliance.  This remedy requires the staff of the facility to 
attend an in-service training program.  The purpose of directed in-service training is to 
provide basic knowledge to achieve and remain in compliance with Federal requirements. 
 
7502.3 - Appropriate Resources for Directed In-Service Training 
Programs 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Facilities should use programs developed by well-established centers of geriatric health 
services education such as schools of medicine or nursing, centers for the aging, and area 
health education centers which have established programs in geriatrics and geriatric 
psychiatry.  If it is willing and able, a State may provide special consultative services for 
obtaining this type of training.  The State or CMS Location may also compile a list of 
resources that can provide directed in-service training and could make this list available 
to facilities and interested organizations.  Facilities may also utilize the ombudsman 
program to provide training about residents rights and quality of life issues. 
 
7502.4 - Further Responsibilities 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The facility bears the expense of the directed in-service training.  After the training has 
been completed, the State will assess whether compliance has been achieved.  If the 
facility still has not achieved substantial compliance, the State Medicaid Agency or the 
CMS Location may impose one or more additional remedies as specified in 42 CFR 
488.206. 
   
7502.5 - Notice of Imposition of Directed In-Service Training 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Directed in-service training may be imposed 15 calendar days after the facility receives 
notice in non- immediate jeopardy situations and 2 calendar days after the facility 
receives notice in immediate jeopardy situations. 
 
7504 - State Monitoring 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7504.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This section is established pursuant to 1819(h)(2)(E)(ii) and 1919(h)(2)(D)(ii) of the 
Act (which cross-refers to 1819(g)(4)(B) and 1919(g)(4)(B) of the Act) and 
42 CFR 488.422 to provide guidance in applying the remedy of State monitoring.  This 
section also explains when State monitoring is imposed and the qualifications for a State 
monitor. 
 
7504.2 - Purpose 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
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. 
 
7504.3 - Qualifications 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Monitors are identified by the State as appropriate professionals to monitor cited 
deficiencies.  A monitor meets the guidelines regarding conflicts of interest in 7202 and: 
 
  Is an employee or contractor of the State; 
 
  Is not an employee or contractor of the monitored facility; and 
 
  Does not have an immediate family member who is a resident of the facility. 
 
7504.4 - When to Impose the State Monitoring Remedy 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The Act requires State monitoring if a facility has been found on three consecutive 
standard surveys to have provided substandard quality of care.  Otherwise, State 
monitoring may be considered an optional remedy.  For example, some situations in 
  which State monitoring may be appropriate include, but are not limited to, the following: 
 
  Poor facility compliance history, e.g., a pattern of poor quality of care, many 
complaints, etc.; 
 
  State concern that the situation in the facility has the potential to worsen; 
 
  Immediate jeopardy exists and no temporary manager can be appointed; 
 
  If the facility refuses to relinquish control to a temporary manager, a monitor may 
be imposed to oversee termination procedures and transfer of residents; or 
 
  The facility seems unable or unwilling to take corrective action for cited 
substandard quality of care.  
 
7504.5 - Frequency 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
When State monitoring is imposed, the State appoints a monitor or monitors.  Monitoring 
may occur anytime in a facility, e.g., the State may determine that ongoing monitoring is 
needed 24 hours a day, 7 days a week, or it may determine that monitoring is only needed 
periodically.  In all instances, monitors have complete access to all areas of the facility, as 
necessary, for performance of the monitoring.  Factors used to determine how often a 
facility is monitored may include, but are not limited to, the following: 
 
  The nature and seriousness of the deficiencies as specified by the State; and 
 
  The timing and frequency of when the problems occurred, e.g., mealtimes, 
evening shifts, daily, etc. 
 
Monitors may be assigned to the facility at these specific times for a specified number of 
days, as determined by CMS or the State, to ensure corrective action. 
 
7504.6 - Duration 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The remedy is discontinued when: 
 
  The facilitys provider agreement is terminated; or 
 
  The facility has demonstrated to the satisfaction of CMS or the State that it is in 
substantial compliance with the requirements and, if imposed for repeated 
substandard quality of care, that it will remain in substantial compliance. 
 
Continued compliance can be demonstrated by adherence to a plan of correction which 
delineates what systemic changes will be made to ensure that the deficient practice will 
  not recur and how the facility will monitor its corrective actions to ensure it does not 
recur. 
 
7506 - Denial of Payment for all New Medicare and Medicaid 
Admissions for Skilled Nursing Facilities and Nursing Facilities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7506.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Sections 1819(h) and 1919(h) of the Act and 42 CFR 488.417 provide for the denial of 
payment for all new Medicare and Medicaid admissions when a facility is not in 
substantial compliance.  Substantial compliance is defined in 42 CFR 488.301 and in 
7001 and guidance on situations likely to be encountered can be found in Appendix P of 
this manual.  This remedy may, and in certain instances, must, be imposed by CMS or the 
State Medicaid Agency.  Denial of payment for new admissions may be imposed alone or 
in combination with other remedies to encourage quick compliance.  Formal notice of the 
imposition and rescission of this remedy may also be provided by the State, as authorized 
by the CMS Location and/or the State Medicaid Agency (See 7311 and 7314.) 
 
7506.2 - Optional Denial of Payment for All New Admissions Remedy 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Sections 1819(h)(2)(B)(i) and 1919(h)(2)(A)(i) of the Act and 42 CFR 488.417(a) cover 
the optional denial of payment for new admissions.  This remedy may be imposed 
anytime a facility is found to be out of substantial compliance, as long as the facility is 
given written notice at least 2 calendar days before the effective date in immediate 
jeopardy situations and at least 15 calendar days before the effective date in non-
immediate jeopardy situations.  CMS will accomplish the denial of payment remedy 
through instructions to the appropriate Medicare Area Contractor and/or the CMS 
Location.  States must have written procedures approved by CMS through their State 
plans on how to apply the denial of payment remedy.  These procedures must be 
approved by the CMS Location. 
 
  Medicare Facilities.  CMS must deny payment to the facility for all new Medicare 
admissions. 
 
  Medicaid Facilities.  The State Medicaid Agency must deny payment to the 
facility, and CMS must deny Federal financial participation to the State Medicaid 
Agency for all new Medicaid admissions. 
 
7506.3 - Mandatory Denial of Payment for All New Admissions Remedy 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(h)(2)(D) and (E) and 1919(h)(2)(C) and (D) of the Act and 
42 CFR 488.417(b) require that, regardless of any other remedies that may be imposed, 
  denial of payment for new admissions must be imposed when the facility is not in 
substantial compliance 3 months after the last day of the survey identifying deficiencies, 
or when a facility has been found to have furnished substandard quality of care on the last 
three consecutive standard surveys (see 42 CFR 488.414). 
 
  Medicare Facilities.  CMS must deny payment to the facility for all new 
Medicare admissions. 
 
  Medicaid Facilities.  The State Medicaid Agency must deny payment to the 
facility, and CMS must deny Federal financial participation to the State 
Medicaid Agency for all new Medicaid admissions to the facility. 
 
7506.4 - Duration and Resumption of Payments 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Generally, if the facility achieves substantial compliance and it is verified in accordance 
with 7317, CMS or the State Medicaid Agency must resume payments to the facility 
prospectively from the date it determines that substantial compliance was achieved.  
However, when payment is denied for repeated instances of substandard quality of care, 
the remedy may not be lifted until the facility is in substantial compliance and the State 
or CMS believes that the facility will remain in substantial compliance.  No payments are 
made to reimburse the facility for the period of time between the date the remedy was 
imposed and the date that substantial compliance was achieved.  CMS accomplishes the 
denial of payment remedy through written instructions to the appropriate Medicare Area 
Contractor in Medicare cases, and in Medicaid cases, through written instructions from 
the CMS Location. 
 
7506.5 - Effect of Remedy on Status of Residents Admitted, Discharged, 
or on Temporary Leave and Readmitted Before, On, or After the 
Effective Date of the Denial of Payment for New Admissions Remedy 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(See also instructions for Fiscal Intermediaries, Pub. 60AB, Program Memorandum AB-
01-131.)  The residents status on the effective date of the denial of payment for new 
admissions remedy is the controlling factor in determining whether readmitted residents 
are subject to the sanction.  Guidelines follow: 
 
  Medicare and Medicaid residents admitted and discharged before the effective 
date of the denial of payment for new admissions remedy are considered new 
admissions if they are readmitted on or after the effective date.  Therefore, they 
are subject to the sanction.  
 
  Medicare and Medicaid residents admitted on or after the effective date of the 
denial of payment for new admissions remedy are considered new admissions.  If 
readmitted after being discharged, they continue to be considered new admissions 
and are subject to the sanction.  
   
  Medicare and Medicaid residents admitted before and discharged on or after the 
effective date of the denial of payment for new admissions remedy are considered 
new admissions if subsequently readmitted.  Therefore, they are subject to the 
sanction.  
 
  Medicare and Medicaid residents admitted on or after the effective date of the 
denial of payment for new admissions remedy who take temporary leave are not 
considered new admissions when they return, but continue to be subject to the 
sanction.  
 
  Private pay residents admitted after the effective date of the denial of payment for 
new admissions remedy and then become eligible for Medicare or Medicaid, are 
subject to the sanction. 
 
  Medicare and Medicaid residents admitted before the effective date of the denial 
of payment for new admissions remedy who take temporary leave before, on, or 
after the effective date of the denial of payment remedy are not considered new 
admissions upon return and, therefore, are not subject to the sanction.  
 
  Private pay residents in a facility prior to the effective date of the denial of 
payment for new admissions remedy who become eligible for Medicare or 
Medicaid on or after the effective date of the denial of payment for new 
admissions remedy are not subject to the sanction.  
 
NOTE:  
 
1.  The term temporary leave refers to residents who leave temporarily for any 
reason.  If residents were not subject to a denial of payment when they went on 
temporary leave, the term indicates that upon return they are not considered 
new admissions for purposes of the sanction.  Therefore, since there is an 
expectation that this resident will return to the facility, the term temporary 
leave is used to justify a resumption of any interrupted payment upon re-entry 
into the facility. 
 
2.  The term discharge refers to individuals who have left the facility and there is 
no expectation that they will return. 
 
3.  Only Part A providers are subject to the denial of payment for new admissions 
remedy. 
 
A resident who is not subject to the denial of payment sanction and goes on temporary 
leave, whether or not there is a leave of absence, is not considered to be a new admission 
for the purposes of the denial of payment remedy, upon his/her return to the facility.  Any 
interrupted payment will be resumed.  In either situation, it is expected that the resident 
will return to the facility following leave. 
   
7508 - Secretarial Authority to Deny All Payment for All Medicare and 
Medicaid Residents 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7508.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(h)(2)(B)(i) and 1919(h)(3)(C)(i) of the Act and 42 CFR 488.418 provide 
that if a facility has not met a requirement, the Secretary may deny any further payment 
to the facility for all Medicare residents, and to a State Medicaid Agency for all Medicaid 
residents in the facility.  This is in addition to the authority to deny payment for all new 
admissions discussed in 7506.  Although either CMS or the State Medicaid Agency may 
deny payment for all new Medicare and/or Medicaid admissions as described in 7506, 
only CMS has the authority to deny all payment for Medicare and/or Medicaid residents.  
(The State, however, may recommend that CMS impose this remedy.)  The denial of all 
payment remedy may be imposed anytime the facility is found to be out of substantial 
compliance (as defined in 42 CFR 488.301), as long as the facility is given written notice 
at least 2 calendar days before the effective date in immediate jeopardy situations and at 
least 15 calendar days before the effective date in non-immediate jeopardy situations.  
CMS will provide the State with timely notification whenever it decides to impose this 
remedy. 
 
Although 1819(h)(2)(B)(i) and 1919(h)(3)(C)(i) of the Act and 42 CFR 488.418(a) 
provide that the Secretary may impose this remedy whenever a facility has not met a 
requirement, it is a severe sanction.  Factors to be considered in selecting this remedy 
could include: 
 
1.  Seriousness of current survey findings; 
 
2.  Noncompliance history of facility; and 
 
3.  Use of other remedies that have failed to achieve or sustain compliance. 
 
7508.2 - Duration and Resumption of Payments 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Generally, if a facility achieves substantial compliance, CMS resumes payments to the 
facility prospectively from the date that it verifies (in accordance with 7317) as the date 
that the facility achieved substantial compliance.  No payments are made to reimburse the 
facility for the period of time between the date the remedy was imposed and the date that 
CMS verifies as the date that the facility achieved substantial compliance.  When CMS 
denies payment for all Medicare residents for three consecutive findings of substandard 
quality of care, the denial of payment cannot be lifted until the facility achieves 
substantial compliance and CMS believes that the facility will remain in substantial 
compliance. 
  Civil Money Penalties 
 
7510 - Basis for Imposing Civil Money Penalties 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The following procedures incorporate 1819(h)(1) and (2)(B) and 1919(h)(1) of the Act 
and 42 CFR 488.430 through 488.444.  CMS or the State may impose a civil money 
penalty for the number of days that a facility is not in substantial compliance with one or 
more participation requirements, or for each instance that a facility is not in substantial 
compliance, regardless of whether the deficiencies constitute immediate jeopardy.  
Additionally, the per day or per instance civil money penalty maybe imposed for past 
noncompliance.  An instance is a single deficiency identified by the tag number used as 
a reference on the CMS-2567 and in Appendix PP of this manual.  There can be more 
than one instance of noncompliance identified during a survey.  (See 7510.2 for 
guidance on past noncompliance.) 
 
NOTE:  The per day and the per instance civil money penalty cannot be used 
simultaneously during a specific survey (i.e., standard, revisit, complaint), 
but both types of civil money penalties may be used during a 
noncompliance cycle if more than one survey takes place and the per day 
civil money penalty was not the civil money penalty initially imposed.  
However, when a per day civil money penalty is the civil monetary 
penalty sanction initially imposed, a per instance civil money penalty 
cannot be imposed on a subsequent survey within the same noncompliance 
cycle.  
 
The CMS Location or State Medicaid Agency may impose a civil money penalty between 
$3,050 and $10,000 per day of immediate jeopardy, or between $50 and $3,000 per day 
of non-immediate jeopardy, or a per instance civil money penalty from $1,000 to 
$10,000 for each deficiency.   
 
A civil money penalty is a valuable enforcement tool because it can be imposed, under 
certain circumstances, for each day that a facility is out of compliance with participation 
requirements or for each instance of noncompliance.  If imposed, a facility cannot avoid 
the remedy.  The civil money penalty may be imposed immediately or after a facility is 
given an opportunity to correct and a revisit finds that the facility remains out of 
compliance.  However, a menu of remedies from which to choose exists, and a civil 
money penalty may not be the most appropriate choice of remedy in every situation of 
noncompliance.  The imposition of a civil money penalty may be most appropriate when 
a facility is not given an opportunity to correct, when immediate  jeopardy exists, when 
noncompliance is at levels G, H, I, or when there is a finding of substandard quality of 
care.  States and CMS Locations are encouraged to develop methods to ensure that civil 
money penalty amounts are applied consistently within the broad ranges identified at 42 
CFR 488.408.  
 
 
  7510.1  Determining Citations of Past Noncompliance at the Time of 
the Current Survey 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Past noncompliance may be identified during any survey.  For the purpose of making 
determinations of current noncompliance or past noncompliance, the survey team is 
expected to follow the investigative protocols and surveyor guidance.  To cite past 
noncompliance with a specific survey data tag (F-tag or K-tag), all of the following three 
criteria must be met: 
 
1.  The facility was not in compliance with the specific regulatory requirement(s) (as 
referenced by the specific F-tag or K-tag) at the time the situation occurred; 
2.  The noncompliance occurred after the exit date of the last standard (recertification) 
survey and before the survey (standard, complaint, or revisit) currently being 
conducted; and 
3.  There is sufficient evidence that the facility corrected the noncompliance and is in 
substantial compliance at the time of the current survey for the specific regulatory 
requirement(s), as referenced by the specific F-tag or K-tag.   
 
A nursing home does not provide a plan of correction for a deficiency cited as past 
noncompliance because the deficiency is already corrected; however, the survey team 
documents the facilitys corrective actions on the CMS-2567. 
 
Regulations at 42 CFR 488.430(b) provide that a Civil Money Penalty (CMP) may be 
imposed for past noncompliance since the last standard survey.  CMS strongly urges 
States to recommend the imposition of a CMP for past noncompliance cited at the level 
of immediate jeopardy.   
 
When a CMP is recommended, the State Survey Agency notifies the CMS Location 
and/or State Medicaid Agency within 20 days from the last day of the survey that 
determined past noncompliance of its recommendation to impose a CMP.  The CMS 
Location and/or State Medicaid Agency responds to the recommendation within 10 days, 
and if accepted, sends out the formal notice in accordance with the notice requirements in 
7305 and 7520. 
 
7510.2  Documentation of Past Noncompliance Citations on the CMS-
2567 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Past noncompliance may be cited on health and/or life safety code surveys of nursing 
homes.  Past noncompliance may be cited on any type of survey (standard, recertification, 
abbreviated standard, e.g., complaint and revisit).  Data about past noncompliance tags 
are not carried forward to subsequent revisit surveys. 
 
  Past noncompliance is documented at the actual deficiency tag (F-tags for health 
deficiencies or K-tags for life safety code deficiencies) where past noncompliance is 
identified.  A scope and severity determination is assigned to a past noncompliance 
citation.  Surveyors document on the CMS-2567 the nursing homes actions to correct the 
past noncompliance. 
 
CMS or the State indicates in the appropriate data field in the Automated Survey 
Processing Environment system (ASPEN) whether a citation is past noncompliance.  
Tags cited as past noncompliance will appear in tag number order on the CMS-2567.  
The providers plan of correction column on the CMS-2567 will print Past 
noncompliance-no plan of correction required for tags identified as past noncompliance.   
 
The ASPEN Certification Procedures Guide includes technical information about past 
noncompliance citations.  This guide is located at the following Web site address:  
https://www.qtso.com/aspenmanguide.html. 
 
7510.3  Applicability to Disapproval of Nurse Aide Training and 
Competency Evaluation Program 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The provisions of 7809 (NATCEP Disapprovals) apply to findings of past 
noncompliance.  (See also 7809.2.) 
 
7512 - Compliance With Section 1128A of the Social Security Act  
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The CMS Location consults with the CMS Location attorneys office to ensure 
compliance with 1128A of the Act and Department of Justice requirements.  Section 
1128A of the Act requires CMS to offer a hearing before collecting, but not before 
imposing, a civil money penalty. 
 
For nursing facilities, 1919(h)(2) of the Act require States to implement remedies by 
either State statute or regulation.  State law may include additional specific requirements 
that must be met.  Section 1919(h)(8) of the Act requires States to offer a hearing before 
collecting a civil money penalty. 
 
 
7514 - Special Procedures Regarding Compliance Decision and Overlap 
of Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If CMS and the State Medicaid Agency both want to impose civil money penalties on any 
given facility, only CMSs civil money penalty is imposed.  Special procedures specified 
in 7807 implement the provisions of 1919(g)(6) and 1919(g) (7) of the Act as well as 
42 CFR 488.452 regarding whether the State or Federal remedy decision takes 
  precedence in non-immediate jeopardy situations involving non-State operated nursing 
facilities and dually participating facilities. 
 
7516 - Determining Amount of Civil Money Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7516.1 - Range of Penalty Amounts 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Civil money penalties are imposed in increments of $50.00. 
 
1.  Lower Range of Penalty Amounts for Per Day Civil Money Penalty 
 
Penalties in the range of $50 to $3,000 per day may be imposed when immediate 
jeopardy does not exist, but the deficiencies either caused actual harm, or caused no 
actual harm, but have the potential for more than minimal harm.  A civil money penalty 
may not be less than $50.00 per day. 
 
2  Upper Range of Penalty Amounts for Per Day Civil Money Penalty 
 
Penalties in the range of $3,050 to $10,000 per day may be imposed for deficiencies 
constituting immediate jeopardy.  Penalties may also be in the upper range of penalty 
amounts for deficiencies when immediate jeopardy does not exist if a penalty in the lower 
range of penalty amounts was previously imposed and the deficiencies in the same 
regulatory grouping are repeated.  Repeated deficiencies are defined in 7516.3. 
 
2.  Range of Per Instance Penalty Amounts 
 
Penalties in the range of $1,000 to $10,000 per instance(s) may be imposed for 
noncompliance that constitutes actual harm, or for noncompliance that has the potential 
for more than minimal harm.  The terminology per instance is not used to suggest that 
only one instance of noncompliance may be assigned a civil money penalty.  There can 
be more than one instance of noncompliance identified during a survey where the State 
utilizes the per instance civil money penalty as an enforcement remedy.  The total dollar 
amount of the civil money penalty for the instance or multiple instances of 
noncompliance may not exceed $10,000 for that specific survey, and may not be less than 
$1,000 per instance. 
 
  NOTE:  In situations of past noncompliance, see 7510.1 and 7510.2. 
 
7516.2 - Factors Affecting Amount of Penalty 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
(Also see 7400.)  Once the decision is made to impose a civil money penalty for facility 
noncompliance, regardless of whether the noncompliance is current or past, the following 
  factors are considered in determining the specific amount of the civil money penalty to 
impose within the appropriate range: 
 
1.  The facilitys history of noncompliance, including repeated deficiencies.  This 
information may be obtained from: 
 
a. Provider files maintained in the State or the CMS Location from the 
current survey and the past three surveys, and, 
 
b. Facility-specific reports maintained in the Automated Survey Processing 
Environment system (ASPEN) and the Certification and Survey Provider 
Enhanced Reporting system (CASPER), from the current survey and the 
past three surveys;  
 
2.  The facilitys financial condition.  The following is only a suggested list of 
sources for this information and is not intended to represent exclusive or 
mandatory sources of information:  
 
a. Resources available to the facility; 
 
b. Information furnished by the facility (e.g., in the letter notifying the 
facility that civil money penalties are being imposed, ask the facility to 
provide any information that could have an impact on the amount of the 
civil money penalty); 
 
c. Consultation with the Medicare Area Contractor (e.g., ask for pertinent 
facility financial information before CMS sends the notice to the facility 
to impose civil money penalties); or 
 
d. Consultation with the State Medicaid Agency (e.g., ask for pertinent 
facility financial information before CMS sends the notice to impose civil 
money penalties); 
 
3.  Seriousness and scope of the deficiencies.  Appendix P of this manual provides 
guidance about the seriousness and scope of the identified deficiencies.  Appendix 
Q of this manual provides guidance about determining the existence of immediate 
jeopardy. 
 
4.  The relationship of one deficiency to other deficiencies. 
 
5.  The facilitys degree of culpability.  A facility is always responsible for the health 
and safety of its residents.  A facility is culpable if noncompliance causing harm 
or placing a resident at risk of harm is intentional or is a product of neglect, 
indifference, or disregard.  
 
6.  Any other remedies being imposed in addition to the civil money penalty.  
   
7516.3 - Changing Amount of Civil Money Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
When the per instance civil money penalty has been selected as an enforcement remedy, 
the provision for changing the amount of the civil money penalty does not apply and no 
opportunity to correct is provided. 
 
The amount of a per day civil money penalty can be adjusted within a given civil money 
penalty range. 
 
The range of a per day civil money penalty amount may be decreased or increased in 
accordance with the guidance that follows: 
 
1.  Decreasing Per Day Civil Money Penalty Range 
 
If a civil money penalty is imposed for a situation of immediate jeopardy and the 
immediate jeopardy is removed but the noncompliance continues, CMS or the State will 
shift the penalty amount to the lower range of penalty amounts. 
 
2.  Increasing Per Day Civil Money Penalty Range 
 
Before the hearing, and following a revisit showing continued noncompliance, CMS or 
the State may propose to increase the penalty amount for facility noncompliance, which 
after imposition of a lower level penalty amount, becomes sufficiently serious to pose 
immediate jeopardy. 
 
If a civil money penalty is imposed, CMS and the State must increase the penalty amount 
for any repeated deficiencies for which a lower level penalty amount was previously 
imposed, regardless of whether the increased penalty amount would exceed the range 
otherwise reserved for deficiencies when immediate jeopardy does not exist. 
 
3.  Repeated Deficiencies  
 
(See 42 CFR 488.438(d)(3).)  These are deficiencies found at the last standard or 
abbreviated standard survey for which a civil money penalty was imposed and sustained, 
and which are subsequently corrected and the facility is certified in compliance, but 
deficiencies in the same regulatory grouping of requirements are found again at the next 
standard or abbreviated standard survey.  For example, a civil money penalty is imposed 
and sustained in some amount for deficiencies under Quality of Care related to hydration 
(see 42 CFR 483.25(j)) during a standard survey.  These deficiencies are corrected at the 
time of the revisit.  However, at the next survey, the facility has deficiencies in Quality of 
Care related to nutrition.  (See 42 CFR 483.25(i).)  In this situation, if a civil money 
penalty is imposed for the repeated noncompliance, it should be higher than the civil 
money penalty that was previously imposed for the Quality of Care deficiencies 
pertaining to hydration.  
   
If the amount of the civil monetary penalty is modified, a notice is sent to the facility as 
quickly as possible notifying it of the revised penalty amount, the date that the revised 
amount is effective, and an explanation for the changed amount.  The revised amount is 
effective on the date that is verified as the date of the change in the facilitys 
noncompliance. 
 
The following example illustrates how the accrual is calculated when a civil money 
penalty is altered.  
 
EXAMPLE:  A civil money penalty is imposed for 4 days of immediate jeopardy at 
$3,500 per day; the amount is shifted to $1,000 per day when the immediate jeopardy is 
removed; and the facility is in substantial compliance with the requirements on the 11th 
day.  A civil money penalty is imposed for 10 days of noncompliance.  The total amount 
of the penalty is $20,000. [($3,500x4) + ($1,000 x6) = $20,000.]  The revised amount is 
also recorded in the Automated Survey Processing Environment (ASPEN) Civil Money 
Penalty Tracking System. 
 
7516.4  Reduction of a Civil Money Penalty by 50 Percent for Self-
Reporting and Prompt Correction of Noncompliance 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
CMS will reduce a civil money penalty by 50 percent when a facility self-reports and 
promptly corrects a deficiency for which a civil money penalty is imposed by CMS 
provided all of the following conditions are met: 
 
a)  The facility must have self-reported the noncompliance to CMS or the State 
before it was identified by CMS or the State and before it was reported to CMS or 
the State by means of a complaint lodged by a person other than an official 
representative of the nursing home; 
 
b)  Correction of the noncompliance must have occurred on the earlier of either 15 
calendar days from the date of the self-reported circumstance or incident that later 
resulted in a finding of noncompliance or 10 calendar days from the date a civil 
money penalty was imposed; 
 
c)  The facility waives its right to a hearing; 
 
d)  The noncompliance that was self-reported and corrected did not constitute a 
pattern of harm, widespread harm, immediate jeopardy, or result in the death of a 
resident; 
 
e)  The civil money penalty was not imposed for a repeated deficiency that was the 
basis of a civil money penalty that previously received a 50 percent reduction; and 
  f)  The facility has met mandatory reporting requirements for the incident or 
circumstance upon which the civil money penalty is based as required by Federal 
and State law. 
Correction will be determined by CMS or the State with an on-site visit or based upon an 
examination of credible written evidence that CMS or the State can verify without an on-
site visit. 
 
NOTE: Under no circumstances will a facility receive both the 50 percent reduction for 
self-reporting and correcting and the 35 percent reduction for waiving its right to a 
hearing. 
 
7518 - Effective Date of Civil Money Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The per day civil money penalty may start accruing as early as the date that the facility 
was first out of compliance, as determined by CMS or the State.  The per instance civil 
money penalty is for a deficiency or deficiencies within a specific survey (i.e., standard, 
revisit, complaint) up to a maximum of $10,000 for that specific survey.  The effective 
date of the per day civil money penalty will often be the date of the survey because it may 
be difficult to document precisely when noncompliance begins if before the date of 
survey.  For purposes of recording the imposition of the per instance civil money penalty, 
the date of occurrence of the noncompliance may be used.  However, for purposes of 
recording the deficiency on the Form CMS-2567, the effective date of the per instance 
civil money penalty must be the last day of the survey that identified the noncompliance 
against which it is being imposed.  This will permit the input of deficiencies into the 
Automated Survey Processing Environment system (ASPEN). 
 
A civil money penalty cannot be collected until a facility has an opportunity for a hearing 
if it properly requests one.  Allowing an effective date for the accrual of a per day civil 
money penalty to be as early as the date of the noncompliance permits the noncompliance 
to be sanctioned promptly and requires that the facility be notified promptly of the 
imposition of the civil money penalty.  However, if there is undue delay in notifying the 
facility of the civil money penalty, it is possible that the effective date of the penalty 
could be moved to a date later than the date of the noncompliance.  (See 7306 regarding 
timing of civil money penalties.) 
 
7520 - Notice of Imposition of Civil Money Penalty 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The State notifies the facility of the possibility of a civil money penalty being imposed 
for noncompliance in its initial letter to the facility after the survey.  The State may: 
 
  Recommend that the CMS Location and/or the State Medicaid Agency impose the 
civil money penalty promptly as a result of noncompliance found during a 
standard, complaint, or revisit survey; 
 
    Recommend that a civil money penalty accrue from the date of the 
noncompliance as a result of a revisit substantiating the facilitys failure to correct 
the noncompliance; 
 
  Recommend that the CMS Location and/or the State Medicaid Agency impose a 
civil money penalty for each instance that results in a deficiency during a survey; 
and 
 
  Recommend a civil money penalty upon identification of past noncompliance. 
The specific procedures specified in 7306, Timing of civil money penalties, 
are followed.  
 
NOTE:  Both the per day and the per instance civil money penalties cannot be 
recommended for the same survey.  
 
However, upon the CMS Locations and/or the State Medicaid Agencys acceptance of 
the States recommendation, the CMS Location or the State Medicaid Agency issues a 
formal notice, as specified in 7305.  The formal notice also incorporates the specific 
civil money penalty information below.  Since the civil money penalty may start accruing 
as early as the date of the finding of noncompliance found during the standard survey or a 
complaint survey, it is important that the CMS Location or the State Medicaid Agency 
send the formal notification of the imposition of the civil money penalty to the facility as 
quickly as possible. 
 
 
7520.1 - Responsibility for Issuing Notice 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
CMS sends a written notice of the imposition of the civil money penalty when CMS is 
imposing the civil money penalty on a skilled nursing facility, nursing facility, or dually 
participating facility.  The State Medicaid Agency sends a written notice of the 
imposition of the civil money penalty when the State Medicaid Agency is imposing a 
civil money penalty on a non-State operated nursing facility. 
 
7520.2 - Content of Notice 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
In addition to the notice requirements in 7305, the following civil money penalty 
information is included: 
 
1.  The nature of the noncompliance (regulatory requirements not met); 
 
2.  The statutory basis for the civil money penalty; 
 
3.  The amount of the penalty per day of noncompliance or the amount of the penalty 
per instance of noncompliance during a survey; 
   
4.  The factors that were considered in determining the amount of the civil money 
penalty; 
 
5.  The date on which the per day civil money penalty begins to accrue; 
 
6.  A statement that the per day civil money penalty will stop accruing on the date on 
which the facility comes into substantial compliance or is terminated from 
participation in the program; 
 
7.  When the civil money penalty is collected; 
 
8.  Statement of the facilitys right to a hearing and information about how to request 
a hearing; and 
 
9.  Implications of waiving the right to a hearing and information about how to waive 
the right to a hearing.  (See 7526.2.) 
 
7522 - Duration of Civil Money Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The per day civil money penalty accrues for the number of days of noncompliance from 
the date that the deficiency starts until the date that the facility achieves substantial 
compliance or, if applicable, the date of termination.  For example, if a facility is found in 
substantial compliance or its provider agreement is terminated on May 18, the accrual of 
the civil money penalty stops on May 17. 
 
The per instance civil money penalty is imposed for each instance of noncompliance 
based on a deficiency during a specific survey.  It is applied to as many instances as is 
deemed appropriate during a specific survey up to a total of $10,000. 
 
EXAMPLE:  When the per instance civil money penalty is used on the original survey, 
the revisit is considered another survey to determine compliance.  If noncompliance is 
identified and a civil money penalty is selected as the enforcement response, either the 
per instance or per day remedy may be selected. 
 
7522.1 - Revisit Identifies New Noncompliance and Same Data Tag is 
Selected 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If the same data tag is selected to identify noncompliance, the State (or the CMS 
Location) could choose to utilize either the per instance or per day civil money penalty as 
an enforcement remedy.  It would not matter whether the same data tag was selected to 
identify the new noncompliance.  The issue is whether noncompliance is present and 
whether the deficient practice rises to a level that will support selecting a civil money 
penalty as an enforcement remedy.  For instance, noncompliance was identified at Tag 
  323 during the original survey.  During the revisit survey, a different problem dealing 
with the elopement of three residents was cited at Tag 323.  The per instance or per day 
civil money penalty would be selected for the noncompliance identified at Tag 323.  If 
the per instance civil money penalty was used, the amount of the civil money penalty 
might be influenced by factors leading to the elopement.  However, only one per instance 
civil money penalty would be appropriate.  It would not be appropriate to assign a 
separate civil money penalty for each of the elopements (findings) identified at Tag 323. 
 
7522.2 - Revisit Identifies New Noncompliance and a Different Data Tag 
is Selected 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If a revisit identifies new deficiencies at a different data tag, either a per instance or per 
day civil money penalty could be selected as an enforcement remedy. 
 
7522.3 - Noncompliance - Immediate Jeopardy Does Not Exist 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
For noncompliance that does not pose immediate jeopardy, the per day civil money 
penalty is imposed for the days of noncompliance, i.e., from the day the penalty starts 
(and this may be prior to the notice), until the facility achieves substantial compliance or 
the provider agreement is terminated.  However, if the facility has not achieved 
substantial compliance at the end of 6 months from the last day of the original survey, the 
CMS Location terminates and the State may terminate the provider agreement.  The 
accrual of the civil money penalty stops on the date that the provider agreement is 
terminated.  
 
For noncompliance that does not pose immediate jeopardy, the per instance civil money 
penalty is imposed for the number of deficiencies during a survey for which the civil 
money penalty is determined to be an appropriate remedy.  For example, Tag 314 and 
Tag 312 were cited on a survey.  A civil money penalty of $2,000 is imposed for Tag 312 
and a civil money penalty of $8,000 is imposed for Tag 314.  Or, a civil money penalty of 
$10,000 is imposed for Tag 314.  No civil money penalty could then be imposed for 
additional deficiencies because the total per instance civil money penalty may not 
exceed $10,000 for each survey.  
 
7522.4 - Noncompliance - Immediate Jeopardy Exists 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
For noncompliance that poses immediate jeopardy, CMS or the State must terminate the 
provider agreement within 23 calendar days after the last day of the survey that identified 
the immediate jeopardy if the immediate jeopardy is not removed.  If the life safety code 
survey found the immediate jeopardy, CMS or the State must terminate the provider 
agreement within 23 calendar days after the last day of the life safety code survey.  The 
accrual of the per day civil money penalty stops on the date that the provider agreement  
is terminated.  The per instance civil money penalty is limited to $10,000 per survey. 
   
NOTE:  The per day and the per instance civil money penalty cannot be used 
simultaneously during a specific survey (i.e., standard, revisit, complaint) 
within a noncompliance cycle, but both may be used during a 
noncompliance cycle when more than one survey takes place and the per 
day civil money penalty was not the civil money penalty initially imposed.  
However, if a per day civil money penalty is imposed initially, a per 
instance civil money penalty cannot be imposed on a subsequent survey 
within the same noncompliance cycle. 
 
7524 - Settlement of Civil Money Penalty 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The CMS Location has the authority to settle cases at any time prior to a final 
administrative decision when it imposed the civil money penalty.  The State has the 
authority to settle cases at any time, prior to the evidentiary hearing decision when the 
State Medicaid Agency imposed the civil money penalty. If a decision is made to settle, 
the settlement should not be for a better term than had the facility opted for a 35 percent 
reduction. 
 
7526 - Appeal of Noncompliance That Led to Imposition of Civil Money 
Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7526.1 - Facility Requests Hearing on Noncompliance That Led to 
Imposition of Civil Money Penalty 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Before collecting a civil money penalty, 1128A of the Act requires the Secretary (CMS) 
to conduct a hearing for a facility that properly requests one.  Section 1919(h)(8) of the 
Act requires the State to offer a hearing before collecting a civil money penalty.  
 
1.  CMS Imposes Civil Money Penalty 
 
The procedures to request a hearing specified in 42 CFR 498.40 are followed when CMS 
imposes a civil money penalty on a State-operated facility, a skilled nursing facility, a 
dually participating facility, or any other facility that has undergone a CMS validation 
survey or CMS review of the States findings.  (CMSs review could include a paper 
review of the States survey material.)  The facility should send its request for a hearing 
to the Departmental Appeals Board with copies to the State and CMS Location.   
 
2.  State Imposes Civil Money Penalty. 
 
The procedures to request a hearing specified in 42 CFR Part 431 are followed when the 
State imposes a civil money penalty on a non-State operated nursing facility that has 
  undergone neither a CMS validation survey nor a CMS review of the States findings 
resulting in a CMS/State disagreement. 
 
3.  Review of Civil Money Penalty 
 
When the basis for imposing the civil money penalty exists, the Administrative Law 
Judge or State hearing officer (or higher administrative review authority) may not: 
 
a.  Set a civil money penalty of zero or reduce a civil money penalty to zero; 
 
b.  Review the exercise of discretion by CMS or the State to impose a civil money 
penalty; 
 
For civil money penalties, an appeal of the level of noncompliance found by CMS in a 
skilled nursing facility or nursing facility is limited to situations in which a successful 
challenge of the issue would affect the range of civil money penalty amounts that CMS 
could collect; that is, a civil money penalty imposed in the upper range of penalty 
amounts for a situation of immediate jeopardy.  The States conclusion about a nursing 
facilitys level of noncompliance must be upheld unless clearly erroneous. 
 
7526.2 - Facility Waiver of Right to Hearing 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
A facility may waive the right to a hearing in writing within 60 calendar days from the 
date of the notice of imposition of the civil money penalty. 
 
If a facility waives its right to a hearing in writing within 60 calendar days from the date 
of the notice of imposition of the penalty, the CMS Location or the State Medicaid 
Agency reduces the civil money penalty amount by 35 percent.  After receipt of the 
waiver, the CMS Location or the State Medicaid Agency notifies the facility of receipt of 
the waiver request. 
 
If a facility does not waive its right to a hearing in accordance with specified procedures, 
the civil money penalty is not reduced 35 percent. 
 
NOTE:  Each time a survey is conducted within an already running noncompliance 
cycle and a civil money penalty is imposed, the facility is given appeal 
rights and may exercise its waiver of right to a hearing. 
 
When a per day civil money penalty is imposed and then increased or decreased at 
subsequent surveys during an already running noncompliance cycle, a facility may elect 
to either appeal each separate imposition of civil money penalty or waive the right to 
appeal each imposition.  Each civil money penalty imposition is computed separately for 
a set number of days.  The final civil money penalty amount is established after the final 
administrative decision. 
 
  EXAMPLE:  A civil money penalty is imposed for 10 days at $1,000 per day.  The 
amount is increased to $3,500 per day for 4 days after a revisit finds immediate jeopardy.  
The civil money penalty is reduced, after the immediate jeopardy has been removed, to 
$100 per day for 20 days of noncompliance after which the facility is found to be in 
substantial compliance.  The total amount of the penalty is $26,000 [($1,000 x 10 days) + 
($3,500 x 4 days) + ($100 x 20 days) = $26,000.]  The facility chooses to appeal the first 
and third civil money penalty amounts imposed, $10,000 + $2,000, and to waive the right 
to appeal the second civil money penalty imposed, $14,000.  The $14,000 amount is 
reduced by 35 percent and the amount due is $9,100.  The final amount of the first and 
third civil money penalty amounts imposed ($10,000 and $2,000) is established after a 
final administrative decision on the appeal. 
 
When several per instance civil money penalties are imposed during a noncompliance 
cycle, a facility may choose to appeal or waive the right to appeal one or more of the civil 
money penalties, in the same manner as illustrated above for the per day civil money 
penalties. 
 
After the facility achieves substantial compliance or its provider agreement is terminated, 
it is notified of the revised civil money penalty amount due. 
 
7528 - When Penalty Is Due and Payable 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
7528.1  When a Civil Money Penalty Subject to Being Collected and 
Placed in an Escrow Account is Imposed 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When the CMS Location imposes a civil money penalty that is subject to being collected 
and placed in an escrow account as specified at 42CFR 488.431, payment is due on 
whichever of the following occurs first if the facility files an appeal of the enforcement 
action:   
 
1. The date on which the independent informal dispute resolution process is 
completed; or 
 
2. The date which is 90 calendar days after the date of the notice of imposition of the 
penalty.  
 
NOTE: Payment is not due until after the facilitys opportunity to waive its right to 
appeal has passed.  If there is no appeal, CMSs determination becomes final and the 
CMP amount becomes due and payable in accordance with the process in 7213. 
 
3.  NOTE: The collection of a per day civil money penalty may be a two-step 
process.  Under488.431(b)(2), in instances when a facility has not achieved 
substantial compliance at the time a per day civil money penalty can be collected 
and placed in an escrow account, the penalty amount that has accrued from the 
  effective date of the penalty through the date of collection would be collected.  
Another collection would occur later in the process for any final balance 
determined to be due and payable once the facility achieves substantial 
compliance or is terminated from the program.  This two-step process may also 
occur if a revisit results in a per day civil money penalty being reduced to a scope 
and severity level below a G and thus not collected and held on an escrow 
account.  In this case, the amount accrued from the effective date of the penalty 
through the date of the revisit survey would be collected and placed in escrow. 
 
7528.2 - After Final Administrative Decision 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When the CMS Location imposes a civil money penalty, a final administrative decision 
includes an Administrative Law Judge decision and review by the Departmental Appeals 
Board, if the facility requests a review of the Administrative Law Judge decision.  
Payment of a civil money penalty is due 15 calendar days after a final administrative 
decision, upholding the imposition of the civil money penalty, when: 
 
1.  The facility achieved substantial compliance before the final administrative 
decision; or 
 
2.  The effective date of termination occurred before the final administrative 
decision.  
 
7528.3 - No Hearing Requested 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Payment of a civil money penalty is due 15 calendar days after the time period for 
requesting a hearing has expired and a hearing request was not received when: 
 
1.  The facility achieved substantial compliance before the hearing request was due; 
or 
 
2.  The effective date of termination occurred before the hearing request was due. 
 
7528.4 - After Request to Waive Hearing 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Payment of a civil money penalty is due 15 calendar days after receipt of the facilitys 
written waiver of a right to a hearing when: 
 
1.  The facility achieved substantial compliance before receipt of the facilitys 
written waiver of its right to a hearing;  
 
2.  A per instance civil money penalty has been imposed.  Since no opportunity to 
correct is available for the noncompliance against which a per instance civil 
  money penalty is imposed, allowing time for the facility to achieve substantial 
compliance is not a factor in determining when the civil money penalty is due; or  
 
3.  The effective date of termination occurred before receipt of the facilitys written 
waiver of its right to a hearing. 
 
7528.5 - After Substantial Compliance is Achieved 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Payment of a per day civil money penalty is due 15 calendar days after substantial 
compliance is achieved when: 
 
1.  A final administrative decision, upholding the imposition of the civil money 
penalty, is made before the facility achieved substantial compliance; 
 
2.  The facility did not file a timely hearing request before it achieved substantial 
compliance; or  
 
3.  The facility waived its right to a hearing before it achieved substantial 
compliance.  
 
However, the period of noncompliance covered by the civil money penalty may not 
extend beyond 6 months from the last day of the standard health survey. 
 
7528.6  After Effective Date of Termination 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
Payment of a civil money penalty is due 15 calendar days after the effective date of 
termination, if before the effective date of termination: 
 
1.  The final administrative decision was made upholding the imposition of the civil 
money penalty;  
2.  The time for requesting a hearing has expired and the facility did not request a 
hearing; or  
The facility waived its right to a hearing. 
 
7530 - Notice of Amount Due and Collectible 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7530.1 - Contents of Notice 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The following information is included in a notice of the amount due which is sent to the 
facility by the entity imposing the civil money penalty after the final amount due and 
collectible is determined: 
 
  1.  The amount of the penalty per day or the amount of the penalty per instance; 
 
2.  For the per day civil money penalty, the number of days involved; 
 
3.  The total amount due; 
 
4.  The due date of the penalty; and 
 
5.  The rate of interest to be assessed on the unpaid balance on the due date as 
follows: 
 
a.  Medicare Facility.  For Medicare, the rate of interest is the higher of 
either the rate fixed by the Secretary of the Treasury after taking into 
consideration private consumer rates of interest prevailing on the date 
of the notice of the penalty amount due and this rate is published 
quarterly in the Federal Register by the Department of Health and 
Human Services under 45 CFR 30.13(a); or the current value of funds 
rate which is published annually in the Federal Register by the 
Secretary of the Treasury, subject to quarterly revisions.  (The CMS 
Location contacts CMS Headquarters  for the rate of interest 
information.) 
 
b.  Medicaid Facility.  If the State Medicaid Agency imposed the civil 
money penalty on a Medicaid facility, the State specifies the rate of 
interest used. 
 
c.  Dually Participating Facility.  Interest for these facilities is assessed 
at the Federal rate (see a. above). 
 
7530.2 - Method of Payment 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
 
1.  The civil money penalty is payable by check to CMS if the check is rendered by 
the due date. 
 
2.  After the due date of the penalty, the CMS Location or the State Medicaid Agency 
deducts the civil money penalty plus any accrued interest from money owed to the 
facility. 
 
7534 - Disposition of Collected Civil Money Penalty 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
7534.1 - Collected From Medicare or Dually-Participating Facility 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
  The specific use of CMP funds collected from Long Term Care Facilities as a result of 
federally imposed CMPs must be approved by CMS on behalf of the Secretary.  Sections 
1819(h)(2)(B)(ii)(IV)(ff) and 1919(h)(3)(C)(ii)(IV)(ff) of the Act provide that collected 
CMP funds may be used to support activities that benefit residents, including assistance 
to support and protect residents of a facility that closes (voluntarily or involuntarily) or is 
decertified (including offsetting costs of relocating residents to home and community-
based settings or another facility), projects that support resident and family councils and 
other consumer involvement in assuring quality care in facilities, and facility 
improvement initiatives approved by the Secretary (including joint training of facility 
staff and surveyors, technical assistance for facilities implementing quality assurance 
programs, the appointment of temporary management firms, and other activities approved 
by the Secretary). 
 
1.  Requests for approval must be sent to the appropriate CMS Location for review 
and final approval. No later than 45 calendar days after receiving a request for 
approval, CMS will respond with either:  
 
a)  An approval;  
 
b)  A denial, with explanation; or  
 
c)  A request for more information. If CMS requests more information within 
the 45-day period, then the period needed for project approval will be 
extended.  CMS will undertake further review and a final decision will be 
provided to the State by the CMS Location within 30 calendar days of the 
date CMS receives the additional information.  
 
NOTE: If none of the above three actions occurs within 45 days of confirmed CMS 
receipt of a complete project description and request for approval package, the State 
should contact both the CMS Location and QualityAssurance@cms.hhs.gov for priority 
processing. 
 
2.  Requests for approval should contain a description of the proposed use/project 
that includes:  
 
a)  Purpose and Summary: Project title, purpose, and project summary;  
 
b)  Expected Outcomes: Short description of the intended outcomes, 
deliverables, and sustainability;  
 
c)  Results Measurement: A description of the methods by which the project 
results will be assessed (including specific measures);  
 
d)  Benefits to NH Residents: A brief description of the manner in which the 
project will benefit nursing home residents;  
 
  e)  Non-Supplanting: A description of the manner in which the project will 
not supplant existing responsibilities of the nursing home to meet existing 
Medicare/Medicaid requirements or other statutory and regulatory 
requirements; 
 
f)  Consumer and other Stakeholder Involvement: A brief description of 
how the nursing home community (including resident and/or family 
councils and direct care staff) will be involved in the development and 
implementation of the project;  
 
g)  Funding: The specific amount of CMP funds to be used for this project, 
the time period of such use, and an estimate of any non-CMP funds that 
the State or other entity expects to be contributed to the project;  
 
h)  Involved Organizations: List all organizations that will receive funds 
through this project (to the extent known), and organizations that the State 
expects to carry out and be responsible for the project;  
 
i)  Contacts: Name of the State contact person responsible for the project 
and contact information.  
 
NOTE: States must provide information and obtain prior approval from its CMS 
Location for any project for which the State wishes to use CMP funds, and CMS reserves 
the right to disapprove such projects (with prior notice and reconsideration opportunity 
for the State should CMS disapprove the requested project or use).  
 
3.  States may contract with, or grant funds to, any entity permitted under State law 
and approved by CMS provided that the funds are used for CMS approved 
projects to protect or improve nursing home services for nursing home residents, 
and provided that the responsible receiving entity is:  
 
a)  Qualified and capable of carrying out the intended project(s) or use(s);  
 
b)  Not in any conflict of interest relationship with the entity(ies) who will 
benefit from the intended project(s) or use(s);  
 
c)  Not a recipient of a contract or grant or other payment from Federal or 
State sources for the same project(s) or use(s);  
 
d)  Not paid by a State or Federal source to perform the same function as the 
CMP project(s) or use(s). CMP funds may not be used to enlarge or 
enhance an existing appropriation or statutory purpose that is substantially 
the same as the intended project(s) or use(s).  
 
NOTE: States may target CMP resources for projects or programs available through 
various organizations that are knowledgeable, skilled, and capable of meeting the 
  projects purpose in its area of expertise as long as the above criteria are met and the use 
is consistent with Federal law and policy. Examples of organizations that could qualify 
include, but are not limited to, consumer advocacy organizations, resident or family 
councils, professional or State nursing home associations, State Long-term Care 
Ombudsman programs, quality improvement organizations, private contractors, etc. 
 
7534.2 - Collected From Medicaid Facility 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A civil money penalty collected by a State from a Medicaid facility that the State or CMS 
finds deficient must be applied to the protection of the health or property of residents of 
nursing facilities that the State or CMS finds deficient (see 1919(h)(2)(A)(ii) of the Act).  
Statutory examples of appropriate uses by the State of the collected civil money penalty 
include: 
 
1.  State costs related to the operation of a facility pending correction of the 
deficiencies or closure; 
 
2.  Reimbursement of residents for personal funds or property lost at a facility as a 
result of actions by the facility or by individuals used by the facility to provide 
services to residents.  Established procedures for the reimbursement of residents 
are followed; and/or, 
 
3.  Payment for the cost of relocating residents to other facilities. 
 
CMS does not have the authority to endorse, approve, disapprove, or otherwise make 
determinations about suggested uses for civil money penalties.  Instead, States have the 
authority to determine which activities constitute acceptable and beneficial uses of the 
funds.  In addition to the three statutorily specified examples, States have shared creative 
and innovative projects and activities that they have funded to stimulate quality using the 
civil money penalty funds.  Examples of such projects are provided in S&C-09-44, dated 
June 19, 2009. 
 
7534.2.1 - Entities Other Than Nursing Homes May Receive Collected 
Civil Money Penalty Funds from the State 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
When civil money penalties are collected and returned to the State, the statutory 
expectation is that these funds are to be used for purposes that will benefit nursing home 
residents.  Aside from this usage condition and any restrictive State-specific laws, States 
may target these resources for projects or programs available through various interested 
nursing home stakeholders, e.g., facilities, consumer groups, professional nursing home 
associations, ombudsmen, quality improvement organizations, etc.. 
 
7534.3 - Collected From Dually Participating Facility 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
   
A civil money penalty collected from a dually participating facility is apportioned 
commensurate with the relative proportions of Medicare and Medicaid beds at the facility 
actually in use by residents covered by the respective programs on the date the civil 
money penalty begins to accrue, per resident census data in the Automated Survey 
Processing Environment system (ASPEN) at the time of the survey. 
 
1.  The Medicare portion of the collected civil money penalty is deposited as 
miscellaneous receipts of the United States Treasury in the Fines, Penalties, and 
Forfeitures Account. 
 
2.  The Medicaid portion of the collected civil money penalty is returned to the State. 
 
EXAMPLE:  In a dually participating facility that has the capacity to provide care for 
100 residents, 70 residents are in the facility on the date that the civil money penalty 
begins to accrue.  Of the 70 residents, Medicare pays for the care of 15 residents, 
Medicaid pays for the care of 45 residents, and 10 residents pay for their own care.  
Thirty of the total 100 beds are empty.  There are 60 Medicare and Medicaid residents.  
The amount of the civil money penalty is apportioned as follows: 25 percent (15/60) of 
the civil money penalty would be apportioned to the miscellaneous receipts of the United 
States Treasury for Medicare and 75 percent (45/60) is returned to the State to be applied 
to the protection of the health and property of residents of nursing facilities that the State 
or CMS finds deficient.  
 
7534.4  Collected Amounts from a Dually Participating Facility or 
Medicare Facility and Held in Escrow 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
 
A civil money penalty collected from a dually participating facility is apportioned 
between Medicare and Medicaid commensurate with the relative proportions of Medicare 
and Medicaid beds at the facility actually in use by residents covered by the respective 
programs on the date the civil money penalty begins to accrue, per resident census data in 
the Automated Survey Processing Environment system (ASPEN) at the time of the 
survey. 
 
After this apportionment is made, ten percent of the Medicare portion of collected civil 
money penalty funds that are subject to be held in escrow and that remain after a final 
administrative decision will be deposited with the Department of the Treasury.  The 
remaining ninety percent of the collected civil money penalty funds that are subject to be 
held in escrow and that remain after a final administrative decision may not be used for 
survey and certification operations but must be used entirely for activities that protect or 
improve the quality of care for residents. These activities must be approved by CMS as 
provided in Sections 1819(h)(2)(B)(ii)(IV)(ff) and 1919(h)(3)(C)(ii)(IV)(ff) of the Act. 
 
7535 - Use of Civil Money Penalty Funds 
(Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) 
   
Sections 1819(h)(2)(B)(ii)(IV)(ff) and 1919(h)(3)(C)(ii)(IV)(ff) of the Act incorporate 
specific provisions of the Patient Protection and Affordable Care Act, (the Affordable 
Care Act pertaining to the collection and uses of CMPs imposed by CMS when nursing 
homes do not meet requirements for Long Term Care Facilities.   
 
1.  The Act provides that collected CMP funds may be used to support activities that 
benefit residents.  These include, but are not limited to: 
 
a)  Assistance to support and protect residents of a facility that closes (voluntarily or 
involuntarily) or is decertified (including offsetting costs of relocating residents to 
home and community-based settings or another facility); 
 
b)  Projects that support resident and family councils and other consumer 
involvement in assuring quality care in facilities; and  
 
c)  Facility improvement initiatives approved by the Secretary (including joint 
training of facility staff and surveyors, technical assistance for facilities 
implementing quality assurance programs, the appointment of temporary 
management firms, and other activities approved by the Secretary). 
 
2.  CMS, States and others are in general agreement about the types of expenditures 
that should be considered inappropriate for civil money penalty funds.  These 
include, but are not limited to: 
 
a) Making capital improvements to a facility; 
 
b) Paying for items or services that are already the responsibility of the nursing 
home; 
 
c) Funding projects, items or services that are not related to improving the quality of 
life and care of nursing home residents; 
 
d) Projects for which a conflict of interest or the appearance of a conflict of interest 
exists; 
 
e) Long term projects (greater than 3 years); 
 
f)  Temporary manager salaries; and 
 
g) Supplementary funding of federally required services. 
 
7536 - Loss of Nurse Aide Training and Competency Evaluation Program 
or Competency Evaluation Program as a Result of Civil Money Penalty 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  Sections 1819(f)(2)(B) and 1919(f)(2)(B) of the Act and 42 CFR 483.151(b) use the term 
assessed to state that the approval of a nurse aide training and competency evaluation 
program or competency evaluation program is prohibited in a facility which, within the 
previous 2 years, has been assessed a civil money penalty of not less than $5,000.  
Section 7809 provides additional information regarding nurse aide training and 
competency evaluation program and competency evaluation program disapprovals. 
 
7536.1 - Definition of Assessed 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The term assessed is defined to reflect the fact that the civil money penalty may be 
revised on administrative appeal.  The assessed amount of the civil money penalty is the 
final amount determined to be owed after a hearing, waiver of right to a hearing, or 
settlement. 
 
7536.2 - Effective Date for Prohibition of Nurse Aide Training and 
Competency Evaluation Program or Competency Evaluation Program 
When Civil Money Penalty of $5,000 or More Is Assessed 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If a civil money penalty of $5,000 or more is assessed on a facility as a result of current 
or past noncompliance found during a survey, the effective date of the prohibition of the 
nurse aide training and competency evaluation program or competency evaluation 
program specified in the notice cannot be before the time frame for requesting a hearing 
has expired, or after receipt of the written waiver, or later than the date on which a civil 
money penalty of $5,000 or more is upheld on administrative appeal. In accordance with 
42 CFR 483.151, the State notifies the program in writing, indicating the reason(s) for 
withdrawal of approval of the program.  However, students who have started a training 
and competency evaluation program for which approval has been withdrawn must be 
allowed to complete the course. 
 
It is possible for a facility to experience two or more separate disapprovals of its nurse 
aide training and competency evaluation program or competency evaluation program that 
could run concurrently for at least part of the same period of time.  When two periods of 
program disapproval overlap, the program will not be restored until the second 2-year 
disapproval period has been completed.  (See 7809.7) 
 
7550 - Temporary Management  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7550.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  This remedy is established pursuant to 1819(h)(2)(A)(I), 1819(h)(B)(iii), 
1919(h)(1)(A), 1919(h)(2)(A)(iii), 1919(h)(3)(B)(I), and 1919(h)(3)(C)(iii) of the 
Act and 42 CFR 488.415. 
 
7550.2 - Purpose 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A temporary manager may be imposed anytime a facility is not in substantial compliance. 
However, when a facilitys deficiencies constitute immediate jeopardy or widespread 
actual harm and a decision is made to impose an alternative remedy to termination, the 
imposition of temporary management is required.  It is the temporary managers 
responsibility to oversee correction of the deficiencies and assure the health and safety of 
the facilitys residents while the corrections are being made.  A temporary manager may 
also be imposed to oversee orderly closure of a facility. 
 
7550.3 - Authority of Temporary Manager 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A temporary manager has the authority to hire, terminate, or reassign staff; obligate 
facility funds; alter facility procedures; and otherwise manage a facility to correct 
deficiencies identified in the facilitys operation. 
 
7550.4 - Selection of Temporary Manager 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The State will select the temporary manager when the State Medicaid Agency is 
imposing the remedy and will recommend a temporary manager to the CMS Location 
when CMS is imposing the remedy.  Each State should compile a list of individuals who 
are eligible to serve as temporary managers. 
 
The following individuals are not eligible to serve as temporary managers: 
 
  Any individual who has been found guilty of misconduct by any licensing board 
or professional society in any State; 
 
  Any individual who has, or whose immediate family members have, any financial 
interest in the facility to be managed. Indirect ownership, such as through a 
mutual fund, does not constitute financial interest for the purpose of this 
restriction; or 
 
  Any individual who currently serves or, within the past 2 years, has served as a 
member of the staff of the facility.  
 
The State should investigate eligible candidates past performance by reviewing any 
compliance histories in the Automated Survey Processing Environment system (ASPEN) 
of facilities managed by the candidates, and by consulting with the long-term care 
  ombudsman, and State Medicaid Agency, if appropriate.  The State should reject a 
candidate who has demonstrated difficulty maintaining compliance in the past. 
 
The State should select or recommend a temporary manager whose work experience and 
education qualifies the individual to correct the deficiencies in the facility to be managed. 
 
 
7550.5 - Conditions of Temporary Management 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The facilitys management must agree to relinquish control to the temporary manager and 
to pay his/her salary before the temporary manager can be installed in the facility. 
 
The facility cannot retain final authority to approve changes of personnel or expenditures 
of facility funds and be considered to have relinquished control to the temporary 
manager. The temporary manager must be given access to facility bank accounts that 
include Medicare and Medicaid receipts. 
 
The temporary managers salary must be at least equivalent to the prevailing annual 
salary of nursing home administrators in the facilitys geographic area, plus the additional 
costs that would have reasonably been incurred by the facility if the temporary manager 
had been in an employment relationship, e.g., the cost of a benefits package, prorated for 
the amount of time that the temporary manager spends in the facility.  The State is 
responsible for determining what constitutes a facilitys geographic area. 
 
If the facility refuses to relinquish control to the temporary manager, the facility will be 
terminated within 23 calendar days of the last day of the survey if the immediate jeopardy 
is not removed. 
 
7550.6 - Orienting and Supervising Temporary Manager 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The State should provide the temporary manager with an appropriate orientation that 
includes a review of the facilitys deficiencies.  The State may request that the temporary 
manager periodically report on the actions taken to achieve compliance and on the 
expenditures associated with these actions.   
 
7550.7 - Notice of Imposition of Temporary Management 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A temporary manager may be imposed 15 calendar days after the facility receives notice 
in non-immediate jeopardy situations and 2 calendar days after the facility receives notice 
in immediate jeopardy situations. 
 
7550.8 - Duration 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
   
Temporary management continues until a facility is terminated, achieves substantial 
compliance and is capable of remaining in substantial compliance, or decides to 
discontinue the remedy and reassume management control before it has achieved 
substantial compliance. In the latter case, the facility faces termination. 
  
7550.9 - Alternatives to Temporary Management 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
In lieu of temporary management, the State Medicaid Agency may use an acceptable 
alternative, that it has demonstrated to CMSs satisfaction, through an approved State 
plan amendment, is as effective in deterring noncompliance and correcting deficiencies as 
temporary management.  When taking enforcement action in a State with an acceptable 
alternative to temporary management, the CMS Location may also use the alternative. 
 
7552 - Transfer of Residents and Transfer of Residents with Closure of 
Facility 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7552.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This section implements 1819(h)(4), 1919(h)(2)(A)(iv), and 1919(h)(5) of the Act in 
conjunction with 1819(c)(2) of the Act and 42 CFR 488.426. 
 
7552.2 - Responsibility for Transferring Residents 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The State has the ultimate responsibility for transferring Medicare and Medicaid residents 
when a facility is terminated.  In some instances, a facility may assume responsibility for 
the safe and orderly transfer of residents when it is closed or its provider agreement is 
terminated.  However, this does not relieve the State of its ultimate responsibility to 
transfer residents. The goal must be to minimize the period of time during which 
residents are receiving less than adequate care.  CMS is specifying that transfer 
requirements apply only to Medicare and Medicaid residents and not to private pay 
residents.  However, when a facility is closed, regardless of whether the closure is a result 
of action taken by the State or by the facility, the State may have plans available to 
provide assistance in the relocation of private pay residents. 
 
7552.3 - States Prerogative to Close Facility and Transfer Residents 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A finding of immediate jeopardy will not, in and of itself, require the State to close a 
facility and transfer Medicare and Medicaid residents. It could, however, result in the 
immediate termination of a Medicare and/or Medicaid provider agreement and the 
  subsequent transfer of Medicare and/or Medicaid residents. During an emergency, the 
State can permanently or temporarily transfer residents to another facility until the 
original facility is able to care for its residents. 
 
7556 - Termination Procedures for Skilled Nursing Facilities and 
Nursing Facilities When Facility Is Not in Substantial Compliance With 
Participation Requirements  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7556.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(h)(4) and 1919(h)(5) of the Act and 42 CFR 488.456 and 489.53 provide 
for termination of skilled nursing facility and nursing facility provider agreements.  Title 
42 CFR Part 431, Subpart D, provides the appeals process for nursing facilities subject to 
enforcement actions by the State. 
 
Under certain circumstances, Federal regulations provide for payment to a facility beyond 
the effective date of termination as follows: 
 
  Under 42 CFR 489.55, Medicare payment is available for up to 30 days after the 
effective date of termination for inpatient hospital services (including inpatient 
psychiatric hospital services) and post-hospital extended care services furnished 
to a beneficiary who is admitted before the effective date, and home health 
services and hospice care furnished under a plan established before the effective 
date. 
 
  Under 42 CFR 441.11, Federal financial participation may be continued for up to 
30 days after the effective date of termination or expiration of a provider 
agreement, or after an administrative hearing decision that upholds the agencys 
termination or nonrenewal action, as long as the Medicaid payments are for those 
residents admitted to the facility before the effective date of termination or 
expiration, and the Medicaid agency is making reasonable efforts to transfer the 
residents to other facilities or to alternate care. 
 
7556.2 - When There Is Immediate Jeopardy 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
When there is immediate jeopardy to resident health or safety, the enforcing agency must 
complete termination procedures within 23 days from the last day of the survey which 
found the immediate jeopardy if it is not removed before then.  (See 7309 for time 
frames.)  The procedure must not be postponed or stopped unless the immediate jeopardy 
is removed, as verified through onsite verification or review of verifiable documentation.  
If there is a written and timely credible allegation that the immediate jeopardy has been 
removed, CMS or the State will conduct a revisit prior to termination, if possible. 
 
  7556.3 - When There Is No Immediate Jeopardy 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When there is no immediate jeopardy, the State Medicaid Agency may and the CMS 
Location must terminate a facility, or the CMS Location must stop all Federal funding to 
a facility, if the facility does not achieve substantial compliance within 6 months of the 
date of the survey that found it to be of it to be out of compliance.  When an agreement to 
repay is signed by a Medicare facility and the facility fails to achieve substantial 
compliance by the 6th month, the CMS Location stops funding.  (See 7600 regarding 
continuation of payment.) 
 
However, termination is always an option that may be imposed for any facility 
noncompliance regardless of whether immediate jeopardy is present.  When considering 
whether to terminate a facilitys provider agreement, the enforcing entity considers many 
factors, particularly the facilitys noncompliance history (e.g., is it consistently in and out 
of compliance), the effectiveness of alternative remedies when previously used, and 
whether the facility has failed to follow through on an alternative remedy (e.g., directed 
in-service training).  These considerations are not all inclusive but are factors to consider 
when determining whether termination is appropriate in a given case. 
 
 
7600 - Continuation of Payments During Correction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7600.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
These procedures are established pursuant to 1819(h)(2)(C) and 1919(h)(3)(D) of the 
Act and are implemented at 42 CFR 488.450.   States use these procedures when they 
determine that a non-State operated skilled nursing facility, nursing facility, or dually 
participating facility is not in substantial compliance with Federal participation 
requirements, and that an alternative remedy is preferred instead of termination.  If the 
State decides to impose alternative remedies in addition to termination, it does not 
follow these procedures.  (See 7556 for termination procedures.) 
 
7600.2 - Purpose 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The statute permits facilities that are not in substantial compliance to continue to 
participate in the Medicare and Medicaid programs for 6 months without the State 
Medicaid Agency or CMS Location initiating a termination action.  To avoid termination, 
the specific criteria in 7600.3 must be met. 
 
7600.3 - Criteria for Continued Payment During Correction Period   
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
  CMS may continue payments to a facility that is not in substantial compliance for up to 6 
months from the finding of noncompliance when immediate jeopardy does not exist and 
the following criteria are met: 
 
1.  The State finds that it is more appropriate to impose alternative remedies than to 
terminate the facilitys provider agreement; 
 
2.  The State has submitted a plan of correction which is approved by the CMS 
Location; and 
 
3.  The facility (for Medicare) agrees to repay the CMS Location payments received 
if action is not taken according to the approved plan of correction. 
 
The State recommends to the CMS Location how long the facilitys correction period 
should be based on the deficiencies and the facilitys plan of correction.  However, the 
correction period should not exceed 6 months since the statute only authorizes continued 
payments for 6 months.  The plan and timetable for corrective action are equivalent to a 
plan of correction. 
 
7600.4 - Approval of Plan and Timetable for Corrective Action 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The facility must develop a plan of correction within 10 calendar days of the receipt of 
the Statement of Deficiencies.  The State reviews the plan of correction and notifies the 
facility of its acceptability in accordance with 7304.  The State may recommend an 
alternative remedy (or remedies) in lieu of termination.  The plan, timetable, 
recommendation and repayment agreement must be sent to the CMS Location by the 25th 
day following the last day of survey.  The CMS Location has 5 calendar days from the 
date these items are received to respond to the plan of correction.  If the CMS Location 
does not contact the State by the 6th calendar day, the plan of correction is deemed to be 
approved. 
 
7600.5 - Facility Takes Corrective Action According to Its Approved 
Plan of Correction and Has Achieved Substantial Compliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Once the State has determined that a facility has made corrections according to its 
approved plan of correction and the facility has achieved substantial compliance, the 
facility may be certified in substantial compliance and the agreement to repay is void. 
 
7600.6 - Facility Does Not Take Corrective Action According to Its 
Approved Plan of Correction and Has Not Achieved Substantial 
Compliance 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
  If the facility does not take action according to its approved plan of correction and does 
not achieve substantial compliance by the end of the specified period, the CMS Location: 
 
  Terminates a skilled nursing facilitys provider agreement for Medicare; or 
 
  Discontinues Federal funding to the skilled nursing facility for Medicare; and 
 
  Discontinues Federal financial participation to the State for the Medicaid nursing 
facility. 
 
The State Medicaid Agency may terminate the nursing facilitys Medicaid provider 
agreement. 
 
Termination or discontinuation of funding does not relieve the facility of the obligation to 
repay Federal funds received during the correction period. 
 
EXAMPLE:  The State finds a skilled nursing facility out of compliance with its health 
survey on May 15.  The State recommends to the CMS Location that it impose alternative 
remedies in lieu of termination.  The skilled nursing facility has agreed to repay all 
Federal funds if it does not make the needed corrections to achieve substantial 
compliance by August 1.  The agreement to repay would begin for Federal payments 
made on May 15.  On August 1, a revisit reveals that the skilled nursing facility did not 
make the corrections in accordance with its approved plan of correction.  The State will 
notify the CMS Location, and the CMS Location will terminate the skilled nursing 
facilitys provider agreement after providing a 15-day notice to the facility.  In addition, 
the skilled nursing facility will be liable to repay to the CMS Location all the Medicare 
Federal funds it received for the period May 15 - August 1. 
 
7600.7 - Facility Takes Corrective Action According to its Plan of 
Correction But Fails to Achieve Substantial Compliance 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The Medicare facility would not be required to repay the Federal funding received 
because it followed its approved plan of correction.  However, because the facility failed 
to achieve substantial compliance, continued Federal funding beyond 6 months would 
stop, and, the CMS Location will terminate the skilled nursing facilitys provider 
agreement. 
 
7600.8 - Facility Does Not Take Corrective Action According to Its Plan 
of Correction and Has Achieved Substantial Compliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The facility would not be required to repay the Federal funding received because it 
achieved substantial compliance. 
 
  7600.9 - When State Opts for Alternative Remedies in Lieu of 
Termination and Criteria Are Not Met 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If termination is not sought, either by itself or along with another remedy (or remedies), 
or if any of the applicable criteria set forth in subsection 3 are not met, the facility or 
State Medicaid Agency will receive no Medicare or Federal Medicaid payments, as 
applicable, from the last day of the survey until the date that substantial compliance is 
achieved. 
 
If the State recommends an alternative remedy instead of termination and the Medicare 
facility refuses to sign an agreement to repay, CMS has no authority to pay for services 
after the last day of the survey.  If funding has ceased, the State must determine if the 
facility is in substantial compliance before funding can resume. 
 
7700 - Nurse Aide Registry and Findings of Abuse, Neglect, or 
Misappropriation of Property 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7700.1- Notification Procedures- Preliminary Determinations 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If the State makes a preliminary determination, based on oral or written evidence and its 
investigation, that resident neglect, abuse, or misappropriation of property has occurred, 
the State completes the following notification procedures: 
 
1.  Individuals Notified - The State notifies the following individuals in writing 
within 10 working days of the investigation: 
 
a.  Individual(s) implicated in the investigation; and 
 
b.  The current administrator of the facility in which the incident occurred. 
 
2.  Notice Information - The following information is included in the notice: 
 
a.  Nature of the allegation (specific facts); 
 
b.  Date and time of the occurrence; 
 
c.  A statement that the individual implicated in the investigation has a right to a 
hearing and must request the hearing within 30 days from the date of the 
notice.  Provide the individual with the specific information needed to request 
a hearing, such as the name and address of a contact in the State to request a 
hearing;  
 
  d.  Statement that if the individual fails to request a hearing, in writing, within 30 
days from the date of the notice, the presumed substantiated findings will be 
reported to the nurse aide registry or the appropriate licensure authority; 
 
e.  The intent to report findings substantiated by a hearing in writing to the nurse 
aide registry and/or to the appropriate licensure authority; 
 
f.  Consequences of waiving the right to a hearing; 
 
g.  Consequences of a finding through the hearing process that the resident abuse 
or neglect, or misappropriation of property did occur; and 
 
h.  Right of the accused individual to be represented by an attorney at the 
individuals own expense. 
 
7700.2 - Conduct of Hearing for Nurse Aides 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
1- Time frame to Complete Hearing 
 
The State must complete the hearing and the hearing record within 120 days from the day 
it receives the request for a hearing. 
 
2 - Hearing Location 
 
The State must hold the hearing in a manner consistent with State practice at a reasonable 
place and time convenient for the individual. 
 
7700.3- Reporting Findings  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
1 - Reporting to Entities 
 
If the individual waives the right to a hearing or the time to request a hearing has expired, 
or if the hearing finding is that the individual neglected or abused a resident or 
misappropriated a residents property, the substantiated findings must be reported in 
writing within 10 working days to: 
 
1.  The individual; 
 
2.  Current administrator of the facility in which the incident occurred; 
 
3.  The administrator of the facility that currently employs the individual, if it is not 
the same facility in which the incident occurred; 
 
4.  Applicable licensing authorities; and 
   
5.  The nurse aide registry for nurse aides as specified in 42 CFR 483.156 and 
discussed in 4141 of this manual.  Section 4141 discusses the function of the 
registry, the information contained in the registry, and responsibility for the 
registry. 
 
2 - Information Submitted to the Nurse Aide Registry 
 
The following information must be included and remain in the registry permanently, 
unless the finding was made in error, the individual was found not guilty in a court of 
law, or the State is notified of the individuals death.  See 4141.B of this manual. 
 
a.  Documentation of the investigation, including the nature of the allegation and the 
evidence that led to the conclusion that the allegation was valid; 
 
b.  The date of the hearing, if the individual chose to have one, and its outcome; and 
 
c.  A statement by the individual disputing the allegation if the individual chose to 
make one. 
 
3- Information Retained in the Nurse Aide Registry Permanently 
 
The registry removes entries for individuals who have performed no nursing or nursing-
related services for 24 consecutive months, unless the individuals registry entry includes 
documented findings of abuse, neglect, or misappropriation of resident property. 
 
7701 - Reporting Abuse to Law Enforcement and the Medicaid Fraud 
Control Unit 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When the CMS Location or SA substantiates a finding of abuse, the CMS Location or SA 
must report the substantiated findings to local law enforcement and, if appropriate, the 
Medicaid Fraud Control Unit. 
   
  Program Management 
 
7800 - Consistency of Survey Results 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7800.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
This section provides guidance to the CMS Location and State for the development and 
implementation of programs to measure accuracy and improve consistency in the 
application of survey results and enforcement remedies, pursuant to 1819(g)(2)(D) and 
1919(g)(2)(D) of the Act and 42 CFR 488.312. 
 
7800.2 - Measuring Consistency 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
These programs should measure the uniformity of survey findings as well as remedy 
recommendations and enforcement actions as stipulated by the statute.  Such programs 
may include: 
 
1.  Quality assurance or continuous quality improvement teams; and 
 
2.  Outside consultation and evaluation. 
 
However, CMS does not want to limit the types of programs that CMS Locations and 
States use to fulfill this requirement.  Additionally, CMS encourages the CMS Locations 
and States to share with each other innovative and unique methods used to measure 
consistency. 
 
7801 - Sanctions for Inadequate State Survey Performance 
Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(Moved to Chapter 8 of this manual.) 
 
7803 - Educational Programs  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7803.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
This section implements 1819(g)(1) and 1919(g)(1) of the Act and 42 CFR 488.334. 
 
7803.2 - Purpose 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  The purpose of this section is to ensure that long-term care facility staff and residents 
(and their representatives) are knowledgeable about current regulations, procedures, and 
policies relative to survey, certification, and enforcement processes. 
 
7803.3 - Methodology 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The development of educational programs and the methods of presentation are within the 
purview of the agency providing the training as long as the programs cover long-term 
care regulations and the survey and enforcement process. 
 
7803.4 - Suggested Training Modalities 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Suggested training modalities include the following: 
 
  Video tapes; 
 
  Satellite communication; 
 
  Newsletters developed by the State; 
 
  Formal presentations; and 
 
  Informal sessions during or after onsite visits. 
 
7805 - Criteria for Reviewing State Plan Amendments for Specified and 
Alternative Enforcement Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7805.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
This section implements 1919(h)(2)(A) and 1919(h)(2)(B)(ii) of the Act, as well as 
42 CFR 488.303 and 488.406, and it provides guidance to the CMS Locations about 
reviewing, for approval or disapproval, State plan amendments for enforcement remedies 
as specified at 42 CFR 488.406(c). 
 
 
7805.2 - Specified Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Specified remedies are those remedies defined in 1919(h) of the Act as well as 
42 CFR 488.406(b). The State plan must specify the State law or regulations that 
establish these remedies, pursuant to 1919(h)(2)(A) of the Act. 
   
7805.3 - Alternative Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If a State wants to establish a remedy in place of a remedy specified in 42 CFR 
488.406(a) or (b), the State plan should describe the following: 
 
1.  General requirements - These requirements include: 
 
  Timing and notice requirements specified in 42 CFR 488.402(f); 
 
  How the alternative remedy satisfies the statutory intent of the specified 
remedy, i.e., immediate jeopardy, non-immediate jeopardy, prolonged 
noncompliance, and repeat noncompliance situations;  
 
  When the remedy will be applied; 
 
  How the alternative remedy is as effective as the specified remedy in deterring 
noncompliance; 
 
  Factors considered in selecting the remedy; and  
 
  State law or regulations which establish these alternative remedies, pursuant 
to 1919(h)(2)(B)(ii) of the Act. 
 
The States categorization of deficiencies should result in the same scope and harm 
assignment.  
 
2.  Civil Money Penalties - In addition to the general requirements above, the State 
plan should include the following: 
 
  How the fine system distinguishes between fine ranges, i.e., immediate 
jeopardy and non-immediate jeopardy; 
 
  That the fine will be increased if the noncompliance is repeated on the 
next survey; 
 
  How the fine system ensures compliance; and 
 
  How the fine system addresses findings of past noncompliance. 
 
3.  Denial of Payment for New Admissions - Whenever a States remedy is unique 
to its State plan and has been approved by CMS, then that remedy may also be 
imposed by the CMS Location against the Medicare provider agreement of a 
dually-participating facility in that State.  Therefore, if a States ban on 
admissions remedy is determined to be an acceptable State alternative, it must be 
  understood that in dually participating facilities, CMS can impose a States ban on 
admissions remedy only with regard to all Medicare/Medicaid residents.  Only the 
State can ban admissions of private pay residents. 
 
4.  Temporary Management - In addition to the general requirements above, the 
State plan should describe how the alternative remedy could be imposed quickly 
in immediate jeopardy situations. 
 
 
7805.4 - Additional Remedies 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If a State wishes to impose additional remedies to those specified in regulations, the State 
must describe: 
 
  Whether the additional remedy is in category 1, 2, or 3 (see 7400 for description 
of remedy categories); and 
 
  State law or regulations that established these additional remedies. 
 
7807 - State/Federal Disagreements About Timing and Choice of 
Remedies  
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7807.1 - Introduction 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
These procedures are established pursuant to 1919(h)(6) and 1919(h)(7) of the Act and 
42 CFR 488.452 to provide guidance when the CMS Locations findings do not agree 
with the State survey agencys findings.  
 
While CMS expects that in most cases the CMS Location will agree with the State survey 
agencys findings of compliance or noncompliance and the timing of the State survey 
agencys enforcement action, the statute provides specific rules to apply when such 
disagreements occur.  These rules apply to non-State operated nursing facilities and 
dually participating facilities.  In the case of State-operated facilities, the CMS Locations 
decision always prevails because the State survey agency does not make the certification 
of compliance or noncompliance nor does it make any recommendations of enforcement 
actions.  In the case of skilled nursing facilities, the CMS Locations decision always 
prevails. 
 
7807.2 - Disagreement About Whether Facility Has Met Requirements 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
If the State survey agency finds that a facility is not in substantial compliance, but the 
CMS Location finds, either through an onsite survey or review of the State survey 
  agencys findings, that the facility is in substantial compliance, the State survey agencys 
finding prevails. 
 
If the State survey agency finds a facility is in substantial compliance, but the CMS 
Location finds, either through an onsite survey or review of the State survey agencys 
findings, that the facility is not in substantial compliance, the CMS Locations finding 
prevails. 
 
When the CMS Locations finding of noncompliance prevails, it may: 
 
  Impose remedies as specified in 7400; 
 
  Terminate the provider agreement; and/or, 
 
  Stop Federal financial participation to the State for a nursing facility at the end of 
6 months. 
 
7807.3 - Disagreement About Decision to Terminate 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
When both the State survey agency and the CMS Location agree that a facility is not in 
substantial compliance, but disagree as to whether to terminate a facilitys provider 
agreement, the following rules apply: 
 
  If the CMS Location wants to terminate, but the State survey agency does not, the 
CMS Location and the State Medicaid Agency impose the alternative remedies 
(pending the CMS Locations termination at 6 months) and follow the procedures 
in 7600; 
 
  If the State Medicaid Agency wants to terminate, but the CMS Location does not, 
the State Medicaid Agencys decision to terminate a nursing facility prevails as 
long as the termination date is no later than 6 months after the last day of the 
standard health survey; and 
 
  If the facility is dually participating, the decision made for the Medicaid portion is 
applied to the Medicare portion and the CMS Location imposes the decision for 
both programs.  Any applicable appeals of alternative remedies or termination 
would be heard under 42 CFR Part 498. 
 
7807.4 - Disagreement About Timing of Facility Termination 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The State Medicaid Agencys timing of termination prevails as long as it does not occur 
later than 6 months after the last day of the standard health survey and both the State 
survey agency and the CMS Location agree that the facility has not achieved substantial 
compliance and agree that the facility should be terminated. 
   
 
7807.5 - Disagreement About Remedies 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
The law provides that either the State or the CMS Location may impose additional or 
alternative remedies.  For example, if the State decides to terminate a provider agreement 
and the CMS Location chooses to impose a civil money penalty in addition to the 
termination, both the termination and the civil money penalty would be imposed.  If the 
State chooses termination and another remedy, the additional remedy would be imposed.  
However, if both the State and the CMS Location want to impose an additional remedy, 
only the CMS Locations remedy would be applied. 
 
7807.6 - One Enforcement Decision 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Only one entity certifies noncompliance and implements enforcement remedies.  The 
States decision prevails for a nursing facility that is not subject to a validation survey, 
and the facility is entitled to an appeal under the State procedures.  (See 42 CFR Part 
431.)  In the case of a dually participating facility, if the States decision prevails, the 
CMS Location adopts the decision made for the Medicaid portion of the facility and 
applies it to the Medicare portion.  The facility is entitled to a hearing under the Federal 
procedures.  (See 42 CFR Part 498.) 
 
7809 - Nurse Aide Training and Competency Evaluation Program and 
Competency Evaluation Program Disapprovals 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7809.1 - Introduction 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Sections 1819(f)(2)(B)(iii) and 1919(f)(2)(B)(iii) of the Act, as well as 
42 CFR 483.151(b)(2) and 483.151(e), require denial or withdrawal of approval of 
facility-based Nurse Aide Training and Competency Evaluation Programs and 
Competency Evaluation Programs offered by or in a facility which, within the previous 2 
years: 
 
  Has operated under a 1819(b)(4)(C)(ii)(II) or 1919(b)(4)(C)(ii) waiver (see 
4132.1 of this manual); 
 
  Has been subject to an extended or partial extended survey under 
1819(g)(2)(B)(i) or 1919(g)(2)(B)(i) of the Act; or 
 
  Has been assessed a civil money penalty described in the Act at 
1819(h)(2)(B)(ii) or 1919(h)(2)(A)(ii) of not less than $5,000 or has been 
  subject to a denial of payment, the appointment of a temporary manager, 
termination, or, in the case of an emergency, been closed and/or had its residents 
transferred to other facilities.  (See 7536 for additional information regarding 
civil money penalties.) 
 
The program will not be approved if it is offered by or in a facility unless the State makes 
the determination, upon an individuals completion of the program in the facility, that the 
individual is competent to provide nursing and nursing related services in skilled nursing 
facilities or nursing facilities. 
 
Any reversals of Nurse Aide Training and Competency Evaluation Program or 
Competency Evaluation Program denials or withdrawals are limited to the informal 
dispute resolution process. 
 
In accordance with 42 CFR 483.151, the State notifies the program in writing, indicating 
the reason(s) for withdrawal of approval of the program.  However, students who have 
started a program for which approval has been withdrawn must be allowed to complete 
the course.   
 
7809.2 - Applicability to Past Noncompliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The provisions of this section apply to findings of past noncompliance when a civil 
money penalty of $5,000 or more is assessed. 
 
7809.3 - Waiver of Program Disapproval 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
See 4132.1.E of this manual. 
 
7809.4 - Notice 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The State survey agency must notify the State agency responsible for Nurse Aide 
Training and Competency Evaluation Programs/Competency Evaluation Program when it 
determines that denial or withdrawal of program approval is necessary.  That agency, in 
turn, notifies the facility.  If the noncompliance which caused a sanction to be imposed, 
or which caused an extended or partial extended survey to be performed, is successfully 
refuted by the facility or otherwise determined by the State to have been improperly 
cited, the facilitys appeal to restore the Nurse Aide Training and Competency Evaluation 
Program/Competency Evaluation Program approval will be granted. 
 
7809.5 - Change of Ownership 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
  If a facility undergoes a change of ownership after having had approval of its nurse aide 
training and competency evaluation program or competency evaluation program 
withdrawn for 2 years before the 2-year period has expired, the remainder of the 2-year 
period does not carry over to the new owner.  If the facility meets all the other 
requirements for the nurse aide training and competency evaluation program or 
competency evaluation program, its program(s) will be approved.  
 
7809.6 - Ability to Appeal a Finding of Substandard Quality of Care 
that Resulted in the Disapproval of a Nurse Aide Training and 
Competency Evaluation Program 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A facility may appeal the finding of substandard quality of care that resulted in the 
disapproval of its nurse aide training and competency evaluation program. 
 
There are instances when a Medicare-only or dually participating facility has been found 
to have provided substandard quality of care but has not experienced any other adverse 
consequence other than the disapproval of its ability to conduct a nurse aide training and 
competency evaluation program.  These situations provide for a hearing under 42 CFR 
Part 498 even though it is the State that is the responsible party for removing the approval 
of the facility to conduct a program at the facility.  When CMS makes a determination of 
substandard quality of care that leads to the disapproval of a nurse aide training and 
competency evaluation program, this determination provides for a hearing under Part 
498.  For Medicaid-only nursing homes, it is left to the State to determine whether to 
provide a hearing to challenge the substandard quality of care determinations that have 
resulted in the disapproval of a nurse aide training and competency evaluation program.  
Accordingly, notices from States advising Medicare-only or dually participating facilities 
of their loss of approval to conduct a nurse aide training and competency evaluation 
program must provide notice of the appeal rights available under 42 CFR Part 498. 
 
Under the regulations, it is the State, not CMS, that disapproves a facilitys nurse aide 
training and competency evaluation program. While the hearings authorized under 42 
CFR Part 498 are directed at actions initiated by CMS, they are expressly designed to 
confer hearing rights on Medicare-only or dually participating facilities that lose their 
nurse aide training and competency evaluation program authority even when no other 
Federal remedies have been imposed.  If the appeals regulations at 42 CFR Part 498 were 
to be interpreted to permit challenges to a disapproval of nurse aide training and 
competency evaluation programs only when such disapprovals are a result of actions 
taken by CMS, these hearing rights would never be triggered since it is not CMS that 
takes these actions.  This is not a result that was intended by the nurse aide training and 
competency evaluation program appeals regulation that was published on July 23, 1999 
(64 Federal Register 39934). 
 
7809.7  Effective Date of Disapproval of Nurse Aide Training and 
Competency Evaluation Program or Competency Evaluation Program 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
   
The effective date of program disapproval is based on the actual occurrence of each of 
the triggering events, i.e., on the date that a nurse staffing waiver was effective; on the 
last day of the extended (or partial extended) survey; or, when the specified enforcement 
remedy or termination was effective.  The disapproval is not delayed pending the 
outcome of any appeal.  (See 7536.2 for the effective date of disapproval of a nurse aide 
training and competency evaluation program or competency evaluation program resulting 
from a civil money penalty.) 
 
It is possible for a facility to experience two or more separate disapprovals of its nurse 
aide training and competency evaluation program or competency evaluation program that 
could run concurrently for at least part of the same period of time.  When two periods of 
program disapproval overlap, the program(s) will not be restored until the second 2-year 
disapproval period has been completed. 
 
A facilitys nurse aide training and competency evaluation program or competency 
evaluation program will be restored when the facility prevails at informal dispute 
resolution or at a formal hearing where the noncompliance is overturned that either 
caused the extended (or partial extended) survey to be conducted, or caused a specified 
remedy or termination to be imposed. 
 
   
  Disclosure 
 
7900 - Information Disclosed to Public 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
(Also see Handling Public Inquiries, 3300-3320 of this manual.) 
 
As provided in 1819(g)(5) and 1919(g)(5) of the Act and 42 CFR 488.325, the State 
survey agency, the State Medicaid Agency, or CMS must make the following information 
available to the public, upon the publics request, for all surveys and certifications of 
skilled nursing facilities and nursing facilities: 
 
  The fact that a facility does or does not participate in the Medicare/Medicaid 
program; 
 
  The official Statement of Deficiencies and Plan of Correction, Form 
CMS-2567.  If it contains the name of any individual, medical information about 
any identifiable resident, the identity of a complainant, or the address of anyone 
other than an owner of the facility, that information must be blocked out before 
the Form CMS-2567 is released to the public; 
 
  Approved plans of correction, Form CMS-2567.  If the plan of correction contains 
the name of any individual, medical information about any identifiable resident, 
the identity of a complainant, or the address of anyone other than an owner of the 
facility, that information must be blocked out before the Form CMS-2567 is 
released to the public; 
 
NOTE:  The Statement of Deficiencies can be released before the facility has 
completed its plan of correction portion.  However, after a plan of 
correction is submitted and approved, the two portions are released 
simultaneously since they appear on the same form. 
 
  When applicable, a Notice of Isolated Deficiencies Which Cause No Actual Harm 
With the Potential for Minimal Harm (Form A) will be included with the Form 
CMS-2567; 
 
  Facility comments; 
 
  Statements that the facility did not submit an acceptable plan of correction or 
failed to comply with the conditions of imposed remedies, if appropriate; 
 
  Official notices of provider terminations; 
 
  Statistical data on facility characteristics that does not identify any specific 
individual.  42 CFR 401.120 states that records will not be created by compiling 
  selected items from the files to give the requester data such as ratios or 
percentages.  However, if existing documents contain such statistical data (e.g., 
Certification and Survey Provider Enhanced Reporting (CASPER) reports), they 
are subject to release; 
 
  Final appeal results; 
 
  Medicare and Medicaid cost reports; and 
 
  Names of individuals with direct or indirect ownership interest in a skilled nursing 
facility or nursing facility, as defined in 42 CFR 420.201, who have been found 
guilty by a court of law of a criminal offense in violation of Medicare or Medicaid 
law. 
 
7901 - Requesting Public Information 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
The public may request information in accordance with disclosure procedures specified 
in 45 CFR Part 5. 
 
7902 - Charges for Information 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If the public requests copies of the records and information described in 7900 from 
CMS, there will generally be a charge.  Charges should be in accordance with 
42 CFR 401.140 for Medicare and applicable State procedures for Medicaid. 
 
7903 - Time Periods for Disclosing Skilled Nursing Facility/Nursing 
Facility Information 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7903.1 - Information That Must Be Disclosed Within 14 Days of Request 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Upon the publics request, the State survey agency, CMS Location, or State Medicaid 
Agency, where appropriate, must make the following information available to the public 
within 14 calendar days after each item is made available to the facility: 
 
  Statements of Deficiencies and Plan of Correction (Form CMS-2567); 
 
  Separate listings of any Notice of Isolated Deficiencies Which Cause No Actual 
Harm With the Potential For Minimal Harm (Form A); and 
 
  Approved plans of correction (Form CMS-2567) which contain any facility 
response to the Statement of Deficiencies. 
   
7903.2 - Disclosure Time Frames 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
Although the State survey agency or CMS Location may choose to wait as long as 14 
calendar days before disclosing the information listed in 7903.1 above in order to obtain 
a facility response or plan of correction prior to disclosure, the information may be 
disclosed at any time after it has been made available to the facility.  The information 
could be disclosed as quickly as the day after it is made available to the facility, or as 
many as 14 days afterward.  The State survey agency or CMS Location makes the 
determination about the appropriateness of the timing of the disclosure. 
 
In situations generating media interest, the State survey agency should notify the CMS 
Location prior to the initial public release of the Form CMS-2567.  CMS Locations are 
expected to extend the same courtesy to State survey agencies when CMS Location 
survey findings have the potential for high publicity. 
 
7904 - Information Furnished to States Long Term Care Ombudsman 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7904.1 -Information Given to Long Term Care Ombudsman 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
In accordance with 1819(g)(5)(B), 1919(g)(5)(B) of the Act, and 42 CFR 488.325(f), 
the State survey agency must provide the States long-term care ombudsman with the 
following: 
 
  A Statement of Deficiencies reflecting facility noncompliance and, if applicable, a 
separate list of isolated deficiencies that constitute no actual harm with the 
potential for minimal harm; 
 
  Reports of adverse actions specified in 42 CFR 488.406 imposed on a facility; 
 
  Any written response by the facility, including plans of correction and facility 
requests for informal dispute resolution; and 
 
  A facilitys request for an appeal and the results of any appeal. 
 
7904.2 - Federal Surveys 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
For Federal surveys, CMS will contact the State survey agency and provide the information 
needed for the State to notify the ombudsman on CMSs behalf. 
 
 
  7905 - Information Furnished to State by Facility with Substandard 
Quality of Care 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7905.1 - Information Provided to the State Survey Agency by Facility 
 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
To provide for the notice to physicians required under 1819(g)(5)(C) and 
1919(g)(5)(C) of the Act, not later than 10 working days after receiving a notice of 
substandard quality of care (as defined in 42 CFR 488.301), a skilled nursing facility or 
nursing facility must provide the State survey agency with a list of: 
 
  Each resident in the facility with respect to whom a finding of substandard quality 
of care was made; and 
 
  The name and address of his/her attending physician. 
 
7905.2 - Failure to Provide Information Timely 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
A facilitys failure to disclose the information as required in 7905.1 above will result in 
termination of participation or imposition of alternative remedies. 
 
7905.3 - Federal Surveys 
(Rev. 213; Issued: 02-10-23; Effective: 02-10-23; Implementation: 02-10-23) 
 
In the case of a finding of substandard quality of care based on a Federal survey, the CMS 
Location will instruct the facility to provide the necessary information to the State survey 
agency.  
  
7906 - Information Furnished to Attending Physician and State Board 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
7906.1 - State Notification of Noncompliance 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
Not later than 20 calendar days after a skilled nursing facility or nursing facility complies 
with 7905.1, the State survey agency must provide written notice of the noncompliance 
to: 
 
  The attending physician of each resident in the facility with respect to whom a 
finding of substandard quality of care was made; and 
 
  The State board responsible for licensing the facilitys administrator.  
   
7906.2 - Federal Surveys 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
If the finding of substandard quality of care is based on a Federal survey, the State survey 
agency will provide notification of noncompliance to the above parties after receiving the 
necessary information from the skilled nursing facility or nursing facility.  (See 7905.3.) 
 
7907 - Access to Information by State Medicaid Fraud Control Unit 
(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) 
 
In accordance with the procedures in 42 CFR 455.21, the State survey agency must 
provide access to any survey and certification information incidental to a skilled nursing 
facilitys or nursing facilitys participation in Medicare or Medicaid to a State Medicaid 
Fraud Control Unit as defined at 42 CFR Part 1007, consistent with current State law and 
the operating agreement between the State survey agency and the State Medicaid Fraud 
Control Unit. 
  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R213SOM 02/10/2023  Revisions to State Operations Manual  02/10/2023 N/A 
(SOM), Chapter 7 
R161SOM 09/30/2016  Revisions to the State Operations Manual  09/23/2016 N/A 
(SOM) Chapter 7 
R160SOM 09/23/2016  Revisions to the State Operations Manual  09/23/2016 N/A 
(SOM) Chapter 7  Rescinded and replaced 
by Transmittal 161 
R118SOM 06/12/2014  New Guidance Added to Chapter 7  Survey  01/01/2012 N/A 
and Enforcement Process for Skilled Nursing 
Facilities and Nursing Facilities 
R113SOM 04/25/2014  New Guidance Added to Chapter 7  Survey  01/01/2012 N/A 
and Enforcement Process for Skilled Nursing 
Facilities and Nursing Facilities  Rescinded 
and replaced by Transmittal 118 
R97SOM  12/13/2013  State Operations Manual (SOM) Chapter 7,  12/13/2013 N/A 
Revisions for Intermediate Care Facilities for 
Individuals with Intellectual Disabilities 
(ICF/IID) 
R63SOM  09/10/2010  Chapter 7-Survey and Enforcement Process  09/10/2010 N/A 
for Skilled Nursing Facilities and Nursing 
Facilities 
R01SOM  05/21/2004  Initial Issuance of Pub 100-07  N/A  N/A