State Operations Manual 
Chapter 2 - The Certification Process 
 
Table of Contents 
(Rev. 205, 03-11-22) 
 
 
Transmittals for Chapter 2 
 
Identification of Providers and Suppliers and Related Pre-Survey Activities 
 
2000 - Certification Surveys - Citations and Responsibility 
2002 - Meaning of Providers and Suppliers 
2003 - SA Identification of Potential Providers and Suppliers 
2003A - Assisting Applicant Providers and Suppliers 
2003B - Initial Certification Kits 
2003C - Deemed Status Providers/Suppliers, Excluding CLIA 
2004 - Provider-Based Determinations 
2005 - Medicare Health Care Provider/Supplier Enrollment 
2005A - Approval or Denial 
2005A1 - Enrollment Denial Based on MAC Review 
2005A2 - Approval or Denial of Certification Based on Survey 
Findings 
2005A3 - Reconsideration of Denial 
2005A4 - Deemed Providers/Suppliers, Excluding CLIA 
2005B - Deemed Providers/Suppliers Except CLIA - Additional Information 
2005C - Clinical Laboratory Improvement Amendments of 1988 (CLIA) 
Laboratories 
2005D - Supplementary Applications 
2005D1 - Forms CMS-855A or the CMS-855B for Changes in 
Provider/Supplier Information 
2005D2 - Form CMS-855R 
2005E - Changes of Ownership 
2005E1 - CHOW Occurs 
2005E2 - Change in Intermediary as Result of CHOW 
2005E3 - CHOWs Involving Multi-Regional Chain Organizations 
2005E4 - Change of Owners, but Not CHOW 
2005F - Voluntary Terminations 
2008 - Prioritizing SA Survey Workload - Initial Surveys and Recertifications 
2008A - Surveys of New Providers and Suppliers  2008B - Initial Surveys of HHAs 
2008D - Effective Date of Medicare Provider Agreement or Approval for 
Suppliers 
2008E - Administrative Considerations 
2008F - SA Scheduling of Resurveys 
2010 - Ascertaining Compliance With Civil Rights Requirements 
2012 - SA Identifying Eligible Providers and Suppliers 
2016 - Readmission to Medicare or Medicaid Program After Involuntary 
Termination - Reasonable Assurance 
2016A - Readmission Criteria 
2016B - Reasonable Assurance Concept 
2016C - Request for Readmission 
2016D - Reasonable Assurance Surveys 
2016E - Effective Date of Provider Agreement After Reasonable Assurance 
2016F - Readmission of ICF/IID After Termination 
2016G - Under LSC at Time of Readmission 
2017 - Readmission Following Voluntary Termination of Program Participation 
2018 - Reinstatement Following Termination of Swing-Bed - Approval 
 
Hospitals 
2020 - Hospitals - Definition and Citations 
2021  Non-deemed Hospitals 
2021A  Recertification of Non-deemed Hospitals 
2022 - Deemed Status: Hospitals Accredited by an Accrediting Organization with 
a CMS-approved Medicare Hospital or Medicare Psychiatric Hospital 
Accreditation Program 
2022A - Notice that a Participating Hospital Has Been Accredited and 
Recommended for Deemed Status 
2022B - Recertification 
2022C - Notification of Withdrawal or Loss of Deemed Status Acccreditation 
2024 - Hospital Merger/Multiple Campus Criteria 
2026 - Certification of Parts of Institutions as Hospitals 
2026A - Hospitals (Other Than Psychiatric Hospitals) 
2026B - Excluded Non-Service Units May be Appropriate 
2030 - Temporary Waivers Applicable to Rural Hospitals 
2034 - Time Limit on Temporary Waiver 
2036 - Definition, Authority and Requirements for Hospital Providers of Extended 
Care Services (Swing-Beds) 
2037 - Requirements Assessed Prior to Survey for Swing-Bed Approval 
2037A - Request from a Medicare Participating Hospital to Add Swing-Bed  Approval 
2037B - Screening 
2037C - Provider Agreement 
2037D - Calculation of Bed Count 
2037E - Rural Area 
2037F - Certificate Of Need (CON) Approval 
2038 - Survey Procedures for Swing-Bed Approval 
2039 - Post-Survey Procedures for Swing-Bed Hospitals 
2040 - RO Approval Procedures for Swing-Bed Approval 
2042 - Psychiatric Hospitals 
2044 - Psychiatric Hospitals and Deemed Status 
2048 - Distinct Part Psychiatric Hospital 
2048A - General 
2048B - Physical Identification 
2048C - Documentation of Findings 
2050 - Medical-Surgical Unit of Psychiatric Hospitals 
2052 - Nonparticipating Emergency Hospitals 
2052A - Emergency Hospital Services 
2052B - Preparation of Initial Certification 
2052C - Recertification and Follow-Up 
2053 - Medicaid-Only Hospitals 
2053A - Initial Certification of Medicaid-Only Hospitals 
2053B - Certification Surveys of Medicaid-Only Hospitals 
2053C - Change in Certification 
2053D - Termination 
2053E - Complaint Investigation 
2054 - Religious Nonmedical Health Care Institutions (RNHCIs) 
2054.1 - Certification of Religious Nonmedical Healthcare Institutions (RNHCIs) 
2054.1A - Other Medicare Conditions of Coverage 
2054.1B - Valid Election Requirements 
Organ Transplant Programs 
 
  2060 -Organ Transplant Programs 
  2060B  Definitions 
  2060C  Regulatory Background 
  2061  Request for Medicare Approval of an Organ Transplant Program  
  2062  Survey and Approval Procedures for Organ Transplant Programs 
  2062B  Types of Surveys and Related Guidance 
2062C  Determining Level of Deficiency for Clinical Experience (Volume) and     
Outcome Requirements Standards: 
  2062D  Post-Survey Activities 
  2062E  Transmission of Program Approval Information    2062F  Mitigating Factors 
  2063  Relationship Between the Transplant CoPs and Hospital CoPs 
 
Hospices 
2080 - Hospice - Citations and Description 
2080A - Citations 
2080B - Description 
2080C - Hospice Core Services 
2080C.1 - Waiver of Certain Staffing Requirements 
2080C.2 - Contracting for Highly Specialized Services 
2080C.3 - Hospice Nursing Shortage Provision 
2080D - Hospice Required Services 
2080D.1 - Hospice Interdisciplinary Group (IDG) 
2081 - Revoking Election of Hospice Care 
2082 - Discharge from Hospice Care 
2083 - Hospice Regulations and Non-Medicare Patients 
2084 - Hospice Inpatient Services 
2084A - Hospice Provides Inpatient Care Directly 
2084B - Hospice Provides Inpatient Services Under Arrangements 
2085 - Operation of Hospice Across State Lines 
2086 - Hospice Change of Address 
2086A - Effective Date 
2086B - Administrative Review 
2086C - Move After certification Survey 
2087 - Simultaneous Surveys 
2088 - Multiple Locations 
2089 - Survey Requirements When the Hospice Provides Care to Residents of a SNF/NF 
or ICF/IID 
 
Intermediate Care Facilities 
2130 - ICFs/IID  Citations and Description 
2130A - Citations 
2130B - Definitions 
2134 - Distinct Part ICF/IID 
2138 - Approval Procedures for ICFs/IID 
2138A - Initial Certification of ICF/IID 
2138B - Multiple Certification of Dispersed Locations 
2138C - Minimum Size of ICF/IID 
2138D - Interpretive Guidelines for ICFs/IID 
2138E - Survey Report (Form CMS-3070G-I) 
2138F - Application of LSC to ICFs/IID of 16 Beds or Less  2138G - Schedule for Recertification 
2139 - Assessment of ICFs/IID Based on CoPs for Active Treatment 
2139A - Comprehensive Functional Assessment 
2139B - Individual Program Plan (IPP) 
2139C - Program Implementation 
2139D - Program Documentation 
2139E - Program Monitoring and Review 
2140 - Waiver and/or Variance of ICF/IID Requirements 
2140A - ICF/IID Room Size and Occupancy 
2140B - Waiver of LSC 
2141 - Recertifications - ICFs/IID 
2141A - Full 12 Months 
2141B - Conditional 12 Month Agreement Subject to Automatic Cancellation 
Clause 
2141C - Period of Certification Which Expires 60 Days After PoC 
2141D - Extending the Term of ICF/MR TLA 
2142 - Evacuation Drills for ICFs/IID Certified Under the Life Safety Code NFPA 
101, 2000 Edition 
2143 - The Use of Video Cameras in Common Areas in ICF/IID 
 
Spell of Illness Certifications 
2160 - Purpose of Certifying 1861(e)(1) and 1819(a)(1) of the Act Status of 
Hospitals and SNFs 
2160A - Benefit Period Provision 
2160B - Defining Medicare Eligible Individuals Home for Purposes of Durable 
Medical Equipment (DME) and Home Health Benefits 
2160C - Defining Institution for Ambulance Benefit 
2162 - Defining Hospital for Spell of Illness, DME, and Home Health Benefit 
Purposes 
2164 - When to Make Spell of Illness Certification 
2166 - Criteria for Certifying 1819(a)(1) of the Act Status of LTC Facilities Other 
Than SNFs 
2166A - Nursing Services 
2166B - 24-Hour Nursing Services 
2166C - Nurse-Bed Ratio 
2166D - Other Services 
2168 - Additional Development Required for Spell of Illness Certifications 
 
Home Health Agencies (HHAs) 
2180 - HHA  Citations and Description  2180A - Citations 
2180B - Types of Agencies 
2180C - General Requirements 
2180D - Services Provided 
2180E  Application of Home Health Agency Conditions of Participation to 
Patients Receiving Chore Services Exclusively 
2182 - Organization of HHA 
2182.1 - Characteristics Differentiating Branches From Subunits of HHAs 
2182.2 - Guidelines for Determining Parent, Branch, or Subunit 
2182.3 - Processing A Change From Branch to Subunit 
2182.4 - CMS Approval Necessary for Non-Parent Locations 
2182.4A - Notification by HHA to Add Non-Parent Location 
2182.4B - SA Review of Requirement for Branch Determination 
2182.4C - Onsite Monitoring of Approved Branches by the SA 
2182.4D  Drop Sites 
2182.5 - Branch Identification Numbers 
2183 - Separate Entities (Separate Lines of Business) 
2183.1 - Operation of the HHA 
2183.2 - Consumer Awareness 
2183.3 - Staff Awareness 
2184 - Operation of HHAs Cross State Lines 
2185 - HHA Change of Address 
2185.1 - Move after Certification Survey and Before Final Medicare Approval 
2186 - Health Facility-Based HHAs 
2188 - Survey of State-Operated HHAs 
2194 - Surveying Health Maintenance Organization (HMO)-Operated Home 
Health Agencies (HHAs) Providing Home Health Services Through Medicare 
Survey and Certification Process 
2195 - Guidelines for Determining Standard Survey Frequency 
2197  Surveyor Worksheets 
2202 - Outcome and Assessment Information Set (Oasis) Requirements 
2202.1 - OASIS Related Definitions 
2202.2 - History of OASIS 
2202.2A - Current Version of OASIS 
2202.2B - OASIS as Part of the HHAs Comprehensive Assessment 
2202.2C - Incorporation of OASIS Data Items Into the 
Comprehensive Assessment (See 484.55(e)) 
2202.3 - Applicability 
2202.3A - Medicare and Medicaid Patients 
2202.3B - OASIS and the Medicare Home Health Benefit  2202.3C - Non-Medicare/Non-Medicaid Patients 
2202.3D - Skilled Versus Nonskilled Care 
2202.3E - Agencies Serving Medicaid Waiver and State Plan 
Patients 
2202.3F - Patients Turning 18 
2202.3G - Patients Receiving Maternity Services 
2202.4 - Comprehensive Assessment and OASIS Reporting (Refer to 484.20 and 
484.55) 
2202.4A - Comprehensive Assessment and OASIS Collection 
2202.4B - OASIS Encoding and Locking 
2202.4C - OASIS Reporting (Refer to 484.20) 
2202.5 - Outcome-Based Quality Improvement (OBQI) 
2202.5A - Using Outcome Based Quality Monitoring (OBQM) and 
Risk Adjusted OBQI Reports in the Survey Process 
2202.5B - Case-Mix Stratified Sample 
2202.5C - Privacy Act Requirements 
2202.5D - Accessing the OBQM, OBQI, and Process Based Quality 
Improvement (PBQI) Reports 
2202.5E - Role of the OASIS Coordinators in OBQI 
2202.6 - OASIS Instructions 
2202.6A - OASIS Users Manual 
2202.6B - Other Manuals 
2202.6C - Other Teaching Tools 
2202.7 - OASIS and the Medicare Home Health Prospective Payment System 
(PPS) 
2202.8 - Surveying for the OASIS Requirements 
2202.8A - Condition of Participation: Comprehensive Assessment 
of Patients (See 484.55) 
2202.8B - Record Keeping 
2202.8C - Condition of Participation: Reporting OASIS 
Information 
2202.8D - Condition of Participation:  Release of Patient 
Identifiable OASIS Information 
2202.9 - Patient Notification of OASIS Collection and Reporting 
2202.9A - Informing Patients of OASIS Collection and Reporting 
2202.9B - Right to See, Review, and Request Changes 
2202.10 - OASIS and HHAs Seeking Initial Certification 
2202.10A - Determining Compliance With the OASIS 
Transmission Requirements 
2202.10B - HHAs Seeking Initial Certification Through Deemed 
Status  2202.10C - Exceptions to Demonstrating Compliance With OASIS 
Submission Requirements Prior to Approval 
2202.10D - Compliance Dates and PPS 
2202.10E - Instructions for Handling Medicare Patients in HHAs 
Seeking Initial Certification 
2202.10F - Instructions to New HHAs Concerning all Other 
Patients 
2202.11 - Correction Policy 
2202.11A - Determining When to Inactivate an Assessment 
2202.11B - Deleting Assessments 
2202.11C - Types of Corrections an HHA Can Make in HAVEN 
2202.11D - Documentation of Corrected Assessments 
2202.11E - Clinical Implications of Corrected Assessment Records 
2202.11F - Regarding Corrections in Lieu of Required Assessments 
2202.11G - Timeliness of Corrections 
2202.11H - Multiple Corrections in a Record 
2202.12 - OASIS State System 
2202.12A - System  Description 
2202.12B - Administration Requirements 
2202.12C - Validation and Editing Process 
2202.12D - Reports 
2202.12E - Replication to the CMS Repository 
2202.12F - System Security 
2202.12G - Security of Transmission 
2202.12H - Provider Relations 
2202.13 - Protection of the Confidentiality of OASIS Data 
2202.13A - OASIS System of Records 
2202.13B - Protection of Confidentiality Under the Privacy Act of 
1974 
2202.14 - SA and RO Roles and Responsibilities 
2202.14A - State 
2202.14B - Regional Office 
2202.15 - OASIS Education and Training 
2202.15A - State 
2202.15B - RO 
2202.15C - HHAs 
2202.16 - Fax Transmission of OASIS or Other Patient Identifiable Information 
2202.17 - Change of Ownership (CHOW), Merger, and Termination Procedures 
Affecting HHAs and OASIS Requirements 
2202.18 - Wound Ostomy Continence Nurses Society (WOCN) and the National  Pressure Ulcer Advisory Panel (NPUAP) OASIS Guidance 
2202.19 - OASIS Collection on Private Pay (Non-Medicare/Non-Medicaid) 
Patients 
 
Ambulatory Surgical Centers (ASCs) 
2210 - ASCs - Citations and Description 
 
Rural Health Clinics (RHCs) 
2240 - RHCs - Citations and Description 
2242 - Conditions to Be Assessed Prior to Scheduling RHC Survey 
2242A - General 
2242A1 - Location of Clinic 
2242A2 - Medical Direction 
2242A3 - Physician Assistant, Nurse Practitioner, and/or Certified 
Nurse Midwife Staff 
2242B - Clinic Is Determined Ineligible 
2242D - Identifying Clinic as Provider-Based 
2242E - Compliance With Civil Rights Statutes 
2242F - Laboratory Services Provided in RHCs 
2244 - Preparing for RHC Survey 
2246 - Clinics Request to Provide Visiting Nurse Services 
2248 - Clinics Request for Waiver of Staffing Requirements 
2248A - Applying Waiver to Applicants 
2248B - Applying Waiver to Participating RHCs 
2248C - Documentation Demonstrating Efforts to Meet Staffing Requirements 
2248D - Monitoring Waivers 
2248E - Notification 
2249 - RO Notification of RHC Initial Certification Approval 
 
 
Community Mental Health Centers 
2250 - Community Mental Health Centers (CMHC) - Citations and Descriptions 
2250A - Citations and Definitions  
2250B - Special Requirements 
2250C - Partial Hospitalization Services Provided by CMHCs or by Others Under   
Arrangements with the CMHC 
            2251 -   Certification Process  
            2251A - Request to Participate 
            2251B - Processing CMHC Initial Certification Requests, SA Role   
            2251C - Processing CMHC Initial Certification Requests, RO Role                2251D - Center Alleges it is Provider-Based  
            2251E - Voluntary Termination 
            2251F - Involuntary Termination 
 
Critical Access Hospitals (CAHS) 
2254 - CAHS (Critical Access Hospitals) 
2254A - Statutory Citation 
2254B - Regulatory Citation 
2254C - Submission of a State Plan 
2254D - Requirements for Critical Access Hospitals 
2255 - SA Procedures for CAH Approval 
2255A - CAH Applications 
2255B - Pre-Survey Activity 
2255C - Arranging a CAH Survey 
2255D - Onsite  Survey  Activity 
2255E - Preparing a Statement of Deficiencies 
2256 - RO Procedures for CAH Approval 
2256A - Verification Criteria 
2256B - Notification 
2256C - Effective Dates 
2256D - RO Processing Complaints Against a CAH 
2256E - RO Processing Denials or Terminations of a CAH 
2256F - Relocation of CAHs with a Grandfathered Necessary Provider 
Designation 
2256G  Co-Location of Critical Access Hospitals 
2256H  Off-Campus CAH Facilities 
2257 - CAH Anti-Dumping Requirements 
2258 - Advance Directive Requirements for CAHS 
2259 - Procedures for Processing CAH Swing-Bed Applications 
2259A - Definition, Authority and Requirements for CAH Providers of Extended 
Care Services (Swing-Beds) 
2259B - Request from a Medicare Participating CAH to add Swing-bed Approval 
2259C - Pre-Survey Activity 
2259D - Certificate Of Need (CON) Approval 
2260 - Survey Procedures for Swing-Bed Approval 
2261 - Post-Survey Procedures for Swing-Bed CAHS 
2262 - RO Approval Procedures for Swing-Bed Approval 
 
End Stage Renal Disease (ESRD) Facilities 
2270 -  Medicare and ESRD        2270A  ESRD Conditions for Coverage 
      2270B  ESRD Survey and Certification Communication, Information,  
      Tools 
      2270C  Definitions 
  2271  General Requirements for In-center and Home Dialysis Program 
      2271A  Dialysis in Nursing Homes 
      2271B  Dialysis in Hospitals 
2272 - ESRD Facility Classifications  
  2273  Dialysis Modalities and Dialysis-related Services 
2274 - ESRD Survey and Certification Forms  
2274A  Form CMS-855A: Medicare Enrollment Application: 
Institutional Providers 
2274B - 2274B - Form CMS-3427: End Stage Renal Disease Application 
and Survey   and Certification Report 
2274C - Form CMS 670: Survey Team Composition and Workload 
Report  
2274D - Form CMS-2567: Statement of Deficiencies and Plan of 
Correction 
      2274E - Form CMS 2567B: Post Certification Revisit Report 
2274F - Form CMS 1539: Medicare/Medicaid Certification and 
Transmittal 
2276 - SA Control of Form CMS-3427 
2278 - ESRD Survey Procedures 
    2278A - Facility Withdraws Application Prior to Survey 
    2278 B - Certificate of Need (CON) 
    2278 C - Initial RO Approval  
    2278 D - Expansion or Addition of Services  SA/RO Procedures  
    2279 - ESRD CMS Certification Numbers 
2280 - ESRD Survey Activities  
  2281 - Waivers 
2281A - Isolation Room Waiver  
      2281B - Medical Director Waiver 
2281C - Life Safety Code Waiver  
2282 - RO Use of Provider Tie-In Notice, Form CMS-2007, for Suppliers of 
ESRD Program Services (Exhibit 156) 
  2283 - Termination Procedures 
2284 - Specialized Areas of ESRD Oversight  
      2284A - Centralized Dialyzer Reprocessing 
      2284B - ESRD Services across State Lines 
2286 - ESRD Network Participation and Data Submission       2286A - ESRD Network Participation  
    2286B - Furnishing Data and Information for ESRD Program 
Administration (42 CFR  ........................................................... 494.180(h)) 
      2286C  Using ESRD Data 
      2286C.1 - Dialysis Facility Reports and Outcomes Lists 
      2286C.2 - Dialysis Facility Compare 
2287 - ESRD Patient Care Technician (PCT) 
    2287A - PCT Certification  
    2287B - Independent ESRD Facility 
      2287C  Certification and Additional Requirements 
      2287D  State and National Certification Programs for PCTs 
2288  Infection Control Considerations 
 
 
 
Providers of Outpatient Physical Therapy and/or Outpatient Speech Pathology 
Services Specified in 485.701 - 485.729 
2290  Providers of Outpatient Physical Therapy and Speech-Language Pathology 
Services - Citations 
2292 - Types of Organizations, Who May Provide Outpatient Physical Therapy 
and Speech-Language Pathology Services, Specified in 485.701 - 485.729 
2292A - Rehabilitation Agency 
2292B  Rehabilitation Agency Clinic and Public Health Agency 
2292C - Public Health Agency 
2294  Change of Address 
2296  Medicare Approved Sites of Service Provision 
2298  Extension Locations for Rehabilitation Agencies 
2298A  Criteria for Extension Location Approval 
2298B  Extension Location Approval Process 
2298C  Survey of Rehabilitation Agency Extension Locations by SAs 
2298D  Accreditation Organization (AO) Surveys of Rehabilitation Agencies 
2300  Outpatient Physical Therapy and/or Speech-Lanaguage Pathology Services 
at Other Locations such as a Patientss Private Residence, Assisted Living or 
Independent Living Facility 
2302  CMS - 381 Model Letter Requesting Identification of Extension Locations 
2304-- Operation of an Organization on the Premises of a Supplier/Provider 
2306  When a Rehabilitation Agencys Extension Location Becomes Its Primary 
Site 
2308  Relocations of Providers of Outpatient Physical Therapy and Outpatient 
Speech-Language Pathology Services Concurrent with CHOWs 
Comprehensive Outpatient Rehabilitation Facilities (CORFs) 
2360 - CORF - Citations and Description  2362 - Scope and Site of Services 
2364 - CORFS Relationship With Other Providers or Suppliers 
2364A - Shared Space With Another Provider or Supplier 
2364B - Sharing of Equipment 
2364C - Employee Sharing 
2366 - Conversion of OPT/OSP to CORF 
 
Suppliers of Portable X-Ray Services 
2420 - Suppliers of Portable X-Ray Services - Citations 
2422 - Location of Portable X-Ray Service 
2424 - Suppliers Using Improperly Labeled or Post-1974 Equipment 
2424A - Labeling Requirements 
2424B - Request for and Review of Labeling Information 
 
Screening Mammography 
2460 - Mammography 
 
Life Safety Code (LSC) 
2470 - LSC - Citations and Applicability 
2470A - Background 
2470B - Citations for Application to Provider Facilities 
2470C - Citations for Application to ASCs 
2470D - Special Application in ICFs/IID 
2470E - Substitution of State Fire Code for the Life Safety Code (LSC) 
2472  Life Safety Code (LSC) Surveys 
2472A - Authority to Grant Waivers for LSC Surveys 
2472B - Subagreements With State Fire Authorities 
2472C - Coordinating LSC Survey 
2472D - ASC Surveys 
2472E - Involvement of SA Surveyors in LSC Surveys 
2474 - Fire Safety Survey Report Forms (Form CMS-2786 Series) 
2476 - Fire Safety Survey Report - Short Form, Form CMS-2786S 
2476A - Background 
2476B - When to Use Short Form 
2476C - When NOT to Use Short Form 
2476D - Results of LSC Screening Process - SA Review of Completed Form 
CMS-2786S 
2476F - Waivers 
2478 - Application of Fire Safety Evaluation System (FSES)  2478A - General 
2478B - Application of System 
2478C - Survey Completion 
2478D - Certification of Compliance with FSES 
2480 - LSC Waivers 
2480A - General 
2480B - Meeting Intent of LSC 
2480C - Elements Considered in Determination of Unreasonable Hardship 
2482 -Technical Bulletins 
2490 - Compliance With 504 of the Rehabilitation Act of 1973, as Amended 
 
Utilization Review 
2496 - Utilization Review (UR) 
2496A - Definition 
2496B - Hospitals 
2496C - SMAs 
2496D - Background and Scope of Work 
2496D1 - Extent of PRO Review 
2496D2 - Availability/Disclosure of QIO Information 
2496E - Action When a QIO Ceases Utilization Review 
2496F - Including UR in Next Scheduled Resurvey 
The Survey Process 
2700 - Conducting Initial Surveys and Scheduled Resurveys 
2700A - Unannounced Surveys 
2700B - SA Schedule for Conducting Health and Safety Resurveys 
2700C - Coordinating LSC Surveys 
2702 - SA Conducting Unscheduled Surveys 
2702A - Survey Due to Unanticipated Events 
2702B - Change of Size or Location of Provider Institution 
2704 - SA Presurvey Preparation 
2705 - SA Survey Team Workload 
2706 - SA Survey Team Composition 
2708 - Facility Refuses to Allow Survey 
2710 - Reviewing Forms at Beginning of Survey 
2712 - Use of Survey Protocol in the Survey Process 
2713 - During Survey 
2713A - Accompanying Surveyors 
2713B - Physical Contact With Patients/Residents 
2714 - Interviewing Key Personnel  2714.1 - Application of Medicare/Medicaid Requirements to Private Pay Patients 
2715 - Interviewing Residents Using the LTC Survey Process 
2716 - Special Survey of Pharmaceutical Service Requirements in SNFs, NFs, and 
ICFs/IID 
2718 - Assistance in Surveying Psychiatric Hospitals 
2718A - Use of CMS Surveyors 
2718B - CO Responsibility 
2718C - Survey Responsibility 
2718D - RO Responsibility 
2720 - Completing the Survey Report 
2720A - Traditional SRF 
2720B - Specific Items to Consider When Completing SRF 
2720C - Completing ICF/IID Survey Report 
2720D - Completing HHA and SNF/NF Survey Reports 
2722 - Preparation for Exit Conference (Excluding SNFs and NFs) 
2723 - Citing Deficiencies in SNFs and NFs 
2724 - Exit Conference 
2724A - Introductory Remarks 
2724B - Ground Rules 
2724C - Presentation of Findings 
2724D - Closure 
2726 - Summary of SA Certification Actions Performed After Survey 
2727 - Limitations on Technical Assistance Afforded by Surveyors 
2728 - Statement of Deficiencies and Plan of Correction, Form CMS-2567 
2728A - Statement of Deficiencies 
2728B - PoC 
2728C - Review of PoCs by SA 
2728D - Modifications of PoCs 
2728E - Rejection of Unacceptable PoCs 
2728F - Major Deficiencies Requiring Long-Term Correction in Hospitals, SNFs, 
NFs, SNF/NFs, and ICFs/IID 
2732 - Follow-Up on PoCS 
2732A - Post-Survey Revisit 
2732B - Form CMS-2567B (See Exhibit 8) 
2732C - Notifying Governing Bodies of Continuing Deficiencies 
2734 - SA Evaluation of Compliance 
2734A - Conditions for Certifying Compliance 
2734B - Certifying Noncompliance 
2736 - The Outcome-Oriented Survey Process  2760 - Forwarding SA Certification  
2762 - Medicare/Medicaid Certification and Transmittal, Form CMS-1539 
2762A - Purpose of Form CMS-1539 
2762B - Definitions of Terms Used on Form CMS-1539 
2762C - Distributing Form CMS-1539 
2762D - Amended Certifications 
2764 - SA Completion Instructions for Certification and Transmittal, Form CMS-
1539, Items 1 - 32 
2764A - In Compliance With Program Requirements 
2764B - Not in Compliance With Program Requirements 
(Termination Development) 
2764C - Not in Compliance With Program Requirements (Denial of 
Payments for New Admissions for SNF, NF, and ICF/IID) 
2764D - Resurvey Does Not Find Significant Progress 
2765 - MAC Tie-In Activities 
2766 - Spell of Illness Supplement, Form CMS-1539A (Exhibit 10) 
2766A - Form(s) to Use 
2766B - Items on Form CMS-1539A 
2772 - Packet of Documentation Attached to Certification and Transmittal by SA 
2774 - Routing of Medicaid-only Certifications 
2776 - RO Requests for Additional Information 
2777 - RO Review of SA Certifications 
2777A - Medicaid-Only Certifications 
2777B - State-Operated Medicaid NFs 
2777C - Medicare Certifications 
2777D - Change in Certification 
2777D1 - Medicaid NF and Medicaid Distinct Part NF Providers 
Seeking to Participate as Medicare SNF Provider 
2777D2 - Medicare- and Medicaid-participating Hospitals Seeking 
to Become Medicaid-Only Hospitals 
2777D3 - Medicaid-Only Hospitals Seeking to Participate in 
Medicare and Medicaid 
 
2778 - Objectives of RO Certification Review 
2779 - RO Assignment of CMS Certification Numbers  
2779A - Numbering System for CMS Certification  Numbers (CCN) 
2779A1  CCN for Medicare Providers 
2779A2  CCN for Suppliers 
2779B  CMS Certification Numbers for Medicaid Providers 
2779C - Special Numbering System for Units of Hospitals That Are Excluded  From the Inpatient Prospective Payment System (IPPS) and Hospitals and CAHs 
with SNF Swing-Bed Approval                                                                                                                             
2779C1- Special Numbering System for IPPS-Excluded Hospitals 
with IPPS-Excluded Units  
2779D - Assigning LTC CMS Certification Numbers 
2779E - Assigning Emergency Hospital CMS Certification Numbers (Non-
Participating Hospitals) 
2779F - Merger of Facilities or CHOW 
2779G - Notification of Change in CMS Certification Numbers 
2779H - Retirement of CMS Certification Numbers 
2779I - Control of CMS Certification Numbers 
2779J - ESRD CMS Certification Numbers 
2779K - HHA Branch CMS Certification Numbers 
2779L  Outpatient Physical Therapy (OPT) Extension CMS Certification 
Numbers 
2780 - Effective Date of Provider Agreement, Form CMS-1561, and Supplier 
Approval 
2780A - Compliance with All Federal Requirements 
2780B - All Health and Safety Requirements Are Not Met on the Day of the 
Survey 
2781 - RO Countersigning Provider Agreement 
2782 - RO Notice of Acceptance 
2783 - Provider Tie-In Notice (Form CMS-2007) 
2783A  Purpose 
2783B  CMS Responsibility for Form CMS-2007 Completion 
2783C - CMS Completion of Form CMS-2007 
2783D  Distribution 
2784 - Effective Date of Certification of Coverage for Suppliers of Services 
2800 - Strikes at Participating Facilities 
Organ Procurement Organizations 
2810 - Organ Procurement Organizations (OPOs)  Citations - Statutory Authority 
2810.1 - Definitions 
2811 - OPO Requirements for Certification 
2812 - OPO Designation Requirements 
2812.2 - Waivers 
2812.3 - Opening the Donation Service Area (DSA) for Competition from other 
OPOs (42 CFR 486.316) 
2812.4 -  Application 
2812.5 -  Application Review 
            2812.6 - Selection Process  
  2812.7 - OPO Transition    2812.8 - No OPO applications for the open DSA 
2813 - Re-Certification Cycle (42 CFR 486.309) 
2814 - Change in Control/Ownership or Service Area (42 CFR 486.310) 
2815 - De-certification and Competition: 
2817 - De-certification and Competition: 
2818 - Involuntary Termination and Non-renewal of an Agreement: 
2819 - Appeals (486.314) 
2820 - Outcome Measures/Data Reporting (486.318, 486.328): NOT 
REVIEWED ON SITE 
2821 - Information Management (486.330): 
 
Federally Qualified Health Centers 
2825 - Federally Qualified Health Centers (FQHCs) - Citations and Description 
2825A - Citations 
2825B - Description 
2826 - RO Approval Process for FQHCs 
2826A - General 
2826B - Information to Be Provided to Potential Applicants 
2826C - Request to Participate 
2826D - Processing Requests 
2826E - RO Assigning Applicants an FQHC CMS Certification Number (CCNr 
2826F - Effective Date 
2826H - Complaint Investigations 
 
Psychiatric Residential Treatment Facilities (PRTF) 
 
2830  Psychiatric Residential Treatment Facilities (PRTF)  Citations and 
Definitions 
2830A - Citations 
2830B  Definitions 
2831  Determination-Making Authority 
2831A - Survey Agency and State Medicaid Agency Interaction 
2831B - Authorization of Certification Expenditures 
2831C - Look-behind Authority on State Determinations 
2831D- Appeals 
2831D.1- State Appeal Rights 
2831D.2- Facility Appeal Rights 
2831E - Accreditation 
2832  Survey Agency, State Medicaid Agency, and PRTF Responsibilities & 
Obligations  2832A - Attestations 
2832B - Plan of Correction (POC) 
2832C - Assigning CMS Certification Numbers (CCN) 
2832D - ASPEN Data Input 
2832E - Multi-State Issues & Interagency Relationships 
2832E.1-State to-State Differences 
2832E.2-Action for Non-Compliance and Termination 
2832E.3-State Agency-Who Can Survey 
2833  Survey Process 
2833A - Survey Types 
2833A.1- Recertification Surveys 
2833A.2- Complaint Surveys 
2833B - Survey Frequency 
2833C - Survey Procedures 
2833C.1- Pre-Survey Procedures 
2833C.2- On-Site Survey Procedures 
2833C.2a- Entrance Conference 
2833C.3- Survey Team Composition 
2833C.4- Information Gathering 
2833C.4a- Task 1- Representative Sample of Residents-Selection Methodology 
2833C.4b- Task 2- Record Review of Individuals in The Sample 
2833C.4c- Task 3- Review of Other Records 
2833C.4d- Task 4- Direct Resident Observations 
2833C.4e- Task 5- Interviews 
2833C.4f- Task 6- Visit to Each Area of The Facility Serving Residents 
2833C.4g- Task 7- Compliance Determination and Preparation For Exit 
Conference 
2834 - Other Applicable SOM Sections 
  Identification of Providers and Suppliers and 
Related Presurvey Activities 
 
2000 - Certification Surveys - Citations and Responsibility 
(Rev. 1, 05-21-04) 
 
Section 1864 of the Social Security Act (the Act) establishes the framework within which 
SAs, under agreements between the State and the Secretary, carry out the Medicare 
certification process.  Sections 1902(a)(9) and (33) of the Act stipulate that the same 
agency is authorized to set and enforce standards for Medicaid.  (The SA may partially 
redelegate the functions to local agencies.) 
 
42 CFR 488 requires the SA to perform surveys to support its certifications.  42 CFR Part 
431, Subpart M, sets forth the functions the SA performs for the SMA.  SAs perform 
initial surveys and periodic resurveys of all providers and certain kinds of suppliers.  
These surveys are conducted to ascertain whether a provider/supplier meets applicable 
requirements for participation in the Medicare and/or Medicaid programs, and to evaluate 
performance and effectiveness in rendering a safe and acceptable quality of care. 
 
Although the regional office (RO) is ultimately responsible for deciding whether a 
provider/supplier may participate in the Medicare program, certification is an SA function.  
After the SA completes an inspection for the Medicare program, it submits evidence and a 
certification recommendation for a final RO determination. When the SA certifies for 
Medicaid purposes, it is reporting its own adjudicative determination. 
 
2002 - Meaning of Providers and Suppliers 
(Rev .40, Issued: 03-20-09, Effective: 03-20-09, Implementation: 03-20-09) 
 
The Medicare law differentiates between providers and suppliers.  The general distinction 
between providers and suppliers is that providers are parties who care for patients 
awaiting, receiving, or recuperating from treatment by intervening practitioners.  The term 
suppliers includes those who furnish goods and services used in care and treatment. 
Medicaid terminology, by contrast, uses provider generically to include all health care 
vendors. (See 42 CFR 431.107(a) and 433.37.)  Medicare providers and suppliers are 
defined at 42 CFR 498.2. 
 
In Medicare, as specified in 1861(u) of the Act, providers include hospitals, critical 
access hospitals (CAHs), skilled nursing facilities (SNFs), home health agencies (HHAs), 
hospices and comprehensive outpatient rehabilitation facilities (CORFs).  Under 
1835(a)(2) of the Act, clinics, rehabilitation agencies, or public health agencies are 
included as providers if such clinic or agency meets the requirements of 1861(p)(4)(A). 
 
Community Mental Health Centers (CMHC) are providers of services for partial 
hospitalization services only.  Providers must meet CoPs or Requirements for SNFs to 
participate in Medicare. (See definitions at 42 CFR 498.2.) 
 
Portable x-ray services, end stage renal disease (ESRD) facilities, ambulatory surgical  centers (ASCs), and organ procurement organizations (OPOs) are suppliers that must meet 
conditions for coverage to participate in Medicare; rural health clinics (RHCs) are 
suppliers that must meet conditions for certification to participate in Medicare.     
 
Federally Qualified Health Centers (FQHCs) are also recognized as suppliers of services 
and provide ambulatory care services similar to those provided by RHCs.  FQHCs may be 
located in urban, as well as rural, areas.  FQHCs are required to meet the same health and 
safety standards as RHCs, with the exception of the certification procedures.  FQHCs self-
attest to their compliance with Medicare conditions for coverage and are only surveyed by 
CMS in connection with complaint investigations. 
 
The above types of suppliers are distinguished from other suppliers, e.g., pharmacies, 
prosthesis suppliers, etc., for which there are no conditions for coverage or certification, 
and which qualify for Medicare through the enrollment process.  Laboratories that 
examine human specimens for the diagnosis, prevention, or treatment of any disease or 
impairment of, or the assessment of the health of, human beings are yet another category 
of suppliers and must meet Clinical Laboratory Improvements of 1988 Act (CLIA) 
requirements. 
 
As previously stated, Medicaid does not distinguish between providers and suppliers. 
Section 1902(a)(27) of the Act provides for agreements with every person or institution 
providing services under the State plan. 42 CFR 431.107(a) refers to all providers of 
services (including individual practitioners and groups of practitioners). 
 
2003 - SA Identification of Potential Providers and Suppliers 
(Rev. 1, 05-21-04) 
 
Often, first indications of interest in program participation by potential participants will be 
contacts with State licensing agencies.  These contacts make the SA aware that a provider 
or supplier wishes to participate. The SA identifies, surveys, and makes certification 
recommendations to CMS or the SMA about providers and suppliers that are potential 
program participants. 
 
2003A - Assisting Applicant Providers and Suppliers  
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Pre-certification assistance to prospective providers and suppliers is a proper certification-
related activity. It may take the form of providing them with a copy of the applicable 
regulations. The objective is to provide the party with information about the requirements 
of the certification component of the process for enrolling and participating in Medicare, 
including compliance with the requirements for SNFs and NFs, Conditions of 
Participation, Conditions for Coverage, or Conditions for Certification, as applicable.  The 
effective date of Medicare participation in accordance with 42 CFR 489.13 may not be 
earlier than the date on which the applicant meets all the federal requirements. 
 
2003B - Initial Certification Kits 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14)   
When an entity seeks to participate in Medicare, it must first complete and submit an 
enrollment application.  Information on enrollment as well as applicable forms and 
instructions may be found at http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/index.html.  Entities subject to survey and 
certification file either a CMS Form 855A -- Medicare Enrollment Application for 
Institutional Providers, or a CMS Form 855B--Medicare Enrollment Application for 
Clinics, Group Practices, and Certain Other Suppliers, or, in some cases, both.  
Prospective providers and suppliers should be aware that the initial review of the Form 
CMS-855A or Form CMS-855B by the Medicare Administrative Contractor (MAC) and 
its recommendation for approval must occur before the on-site initial certification survey 
is conducted and action is taken by the RO. 
 
CMS has established Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS) as an alternative to the paper enrollment process.  Internet-based PECOS allows 
provider and supplier organizations to enroll, make a change in their Medicare enrollment, 
view their Medicare enrollment information on file with Medicare, or check on the status 
of a Medicare enrollment application via the Internet. 
 
When the MAC completes its review of the application, it either:  1) sends the SA and the 
RO its recommendation to approve the applicant; or 2) denies the application.  The SA 
must not perform a survey of an initial applicant until it has received notice from the 
MAC that the information provided on the enrollment application has been verified 
and that the MAC is recommending approval of the application.  A SA may, however, 
start planning for an unannounced survey upon initial contact from an applicant.   
 
(NOTE:  SA surveys of initial applicants must be consistent with the priorities for Federal 
survey work, established by CMS each fiscal year.  Depending upon available resources, 
initial surveys are typically a lower priority and SAs generally should not perform such 
work unless all higher priority Federal work will be completed.  SAs may consult with the 
CMS Regional Office (RO) to determine whether a specific initial applicant would 
address an access to care issue and thus warrants an exception.)  
The prospective provider/supplier must contact the SA for Medicare and/or Medicaid 
certification materials for their provider/supplier type.  The SA mails the initial 
certification materials under cover of the appropriate form letter. (See Exhibits 1A-1F and 
Exhibit 63.)  If the applicant has not contacted the SA before the SA receives the MACs 
recommendation for approval, then the SA contacts the applicant using the phone number 
listed on the application. 
 
Upon receipt of the completed certification materials from the prospective applicant, the 
SA reviews the materials to see that they are properly completed and secures any 
necessary changes or additional information.  It makes sure any required SNF transfer 
agreements are received.  If a distinct part of an organization is being considered for 
program participation, the SA reviews the diagram (or floor plan) submitted to make sure 
the size and location of the distinct part are clearly shown.  The SA works in conjunction 
with the RO and the MAC to gather the appropriate documentation from the entity that 
supports its position of being a distinct part before forwarding the package to the RO, in  order to make a recommendation to the RO. Both copies of the signed provider agreement 
or supplier approval are sent to the RO, along with the Title VI Assurance of Compliance 
with Civil Rights (Form HHS-690).  In title XIX-only cases, the SA sends the Form HHS-
690 or comparable form to the SMA. 
 
If the entity indicates that it is requesting a provider-based determination under the 
Medicare program, the SA must notify the RO immediately.  Distinct Part and Provider-
Based are not synonymous terms.  Determinations concerning provider-based status are 
made by RO Financial Management personnel. 
 
The SA refers questions about enrollment, MACs, payment rules, financial solvency, or 
title VI clearance to the RO or the State Medicaid agency, as appropriate. For questions 
concerning the downloading, completion, and submission of the Form CMS-855A or 
CMS-855B, the provider/supplier should be directed to the CMS Web site or the 
appropriate MAC. 
 
Initial Certifications Involving New Owners who Reject Assignment of the Existing 
Medicare Agreement  
 
In the case of a prospective applicant that is planning to acquire an existing Medicare-
participating provider or supplier, the RO should provide pre-certification assistance to the 
prospective applicant which includes making the prospective applicant aware of the 
consequences of accepting or rejecting assignment of the existing providers/suppliers 
Medicare agreement.  The RO should be consulted if the prospective applicant is 
considering rejecting assignment of the agreement so that the RO can provide detailed 
information on the consequences of such action before the prospective applicant makes a 
final decision and submits an application. 
 
In the case of an applicant that has acquired an existing Medicare-participating provider or 
supplier and has rejected assignment of that entitys Medicare agreement, that applicant is 
considered a new applicant seeking initial certification and the SA must prioritize 
scheduling an initial survey for that applicant accordingly.  This includes adhering to 
workload priorities identified by CMS for surveys of initial applicants to enroll in 
Medicare.  Unless specifically directed by the RO to do so, SAs must not conduct initial 
surveys unless they are able to complete their higher priority workload.  For initial 
applicants that have an accreditation option, initial certification surveys are the lowest SA 
priority.  When an SA conducts an initial certification survey of an applicant that acquired 
a provider/supplier but rejected assignment, the RO must review the facts of the case 
carefully to determine whether the SA deviated from CMS workload priorities as well as 
the SAs typical practice for initial applicants. Such deviation may raise reasonable doubt 
that the survey was unannounced.  
 
Section 2700A of the SOM requires all surveys of providers and suppliers (other than 
clinical laboratories) to be unannounced. This requirement applies to AO as well as SA 
surveys. An unannounced survey provides an opportunity to assess how the provider or 
supplier typically operates. On the other hand, if a provider or supplier knows the exact or 
approximate date of a survey, it may temporarily adjust its typical practices to enhance its  compliance at the time of the survey. In doing so, it presents an unrepresentative picture to 
surveyors of the quality of care typically provided to its patients or residents. It is 
therefore in the best interest of patients and residents that surveys be unannounced.  
 
Given the lead time normally required to schedule and prepare for a full survey, if an 
initial survey takes place shortly after the acquisition date, such timing suggests discussion 
with the new owner prior to the acquisition date to arrange the timing of the survey to 
occur shortly thereafter, compromising the requirement that the survey be unannounced. 
While the new owner, like any other initial applicant to the Medicare program, will be 
expecting to be surveyed at some point, there must be some degree of uncertainty about 
just when that survey will occur, in order to permit an assessment of compliance when the 
facility is operating in a typical manner.  
 
The RO may refuse to accept a SA survey certifying compliance or an AO 
recommendation for deemed status if the survey timing creates reasonable doubt that the 
survey was unannounced.  Each case must be assessed based on the facts specific to it; 
however, any survey that takes place within fourteen days after the effective date of an 
acquisition that involves rejection of assignment of the provider agreement may warrant 
closer review by the RO of the circumstances of the case and the timing of the survey.  
However, it is also possible that the facts of a specific case may indicate that an initial 
certification survey taking place at a later date was announced. 
 
See Section 3210 for more information about policies and procedures related to 
acquisitions of Medicare-participating providers or suppliers. 
 
2003C  Deemed Status Providers/Suppliers, Excluding CLIA 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
There is an alternative to SA surveys for demonstrating compliance with the applicable 
CoPs/CfCs/Conditions for Certification.  Accreditation based on a survey by a CMS-
approved Medicare accreditation program of a national accrediting organization may be 
used by CMS to deem a provider or supplier as complying with the applicable 
regulatory standards.   For certain types of providers/suppliers, for example hospitals or 
psychiatric hospitals, Medicaid will also accept accreditation under a CMS-approved 
Medicare accreditation program as evidence of compliance for Medicaid purposes.   
 
Section 1865(a) of the Act provides that CMS may recognize and approve national 
accrediting organization (AO) Medicare accreditation programs which demonstrate that 
their health and safety standards and survey and oversight processes meet or exceed those 
used by CMS to determine a health care providers or suppliers compliance with 
applicable Medicare CoPs, CfCs, Conditions for Certification or requirements.   
 
The regulations which govern Medicare survey, certification, and enforcement procedures 
are generally found in 42 CFR Part 488.   Section 488.1 defines an accredited provider or 
supplier as a provider or supplier that has voluntarily applied for and has been accredited 
by a national accreditation program meeting the requirements of and approved by CMS in 
accordance with 488.5 or 488.6.  Accreditation under a CMS-approved Medicare  accreditation program is voluntary and is not required for Medicare participation. 
 
Consistent with Section 1865 of the Act, 42 CFR 488.5 and 488.6 permit deemed status 
certification for ambulatory surgical centers; comprehensive outpatient rehabilitation 
facilities; critical access hospitals; home health agencies; hospices; hospitals; clinics, 
rehabilitation agencies or public health agencies providing outpatient physical therapy, 
occupational therapy or speech pathology services; psychiatric hospitals; religious 
nonmedical health care institutions; rural health clinics; screening mammography services; 
skilled nursing facilities; and transplant centers, except for kidney transplant centers.  
However, at this time only certain AOs have requested CMS approval of Medicare 
accreditation programs, and those programs are only for some of these provider/supplier 
types.  A current list of CMS-approved Medicare accreditation programs may be found at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Accreditation.html.  
 
The enrollment and certification requirements also apply to providers/suppliers seeking 
deemed status through their accreditation by a CMS-approved Medicare accreditation 
program.  AOs with approved Medicare accreditation programs are also required by CMS 
not to survey initial applicants until they provide evidence that the MAC has reviewed 
their application and recommended approval. 
 
The prospective provider/supplier seeking deemed status through accreditation must still 
contact the SA for Medicare and/or Medicaid certification materials for their 
provider/supplier type.  The SA mails the initial certification materials under cover of the 
appropriate form letter.  (See Exhibits 1A-1F and Exhibit 63.)  If the applicant has not 
contacted the SA before the SA receives the MACs recommendation, then the SA 
contacts the applicant using the phone number listed on the application. 
 
In the case of a deemed provider or supplier, the SA does not conduct a survey to 
initially certify or recertify compliance with the applicable Medicare CoPs, CfCs, or 
requirements.  Rather, such providers or suppliers are under the jurisdiction of the AO, not 
the SA, for oversight of their ongoing compliance, unless the SA conducts a validation 
survey (either a representative sample or substantial allegation validation survey) at the 
direction of CMS and CMS determines as a result of such validation survey that the 
provider or supplier fails to comply with one or more CoPs, CfCs, Conditions for 
Certification or requirements.  
 
Note that some AOs offer multiple accreditation programs for a given type of provider or 
supplier, but for each provider/supplier type an AO may offer no more than one CMS-
approved Medicare accreditation program.   In addition, some AOs may offer only one 
program for a provider/supplier type, but they offer this program to their customers with 
and without the option of the AO recommending Medicare deemed status to CMS.  Thus, 
it is possible for a healthcare entity to be accredited without being deemed for 
Medicare participation.   For certification purposes, CMS considers only accreditation 
under a CMS-approved Medicare accreditation program where the AO has recommended 
deemed status.  SAs must enter information on the Deemed tab within the certification kit 
in ASPEN only for those initial applicants that are seeking deemed status on the basis of  accreditation under a CMS-approved Medicare accreditation program.  CMS has 
established a process for AOs to provide notice to the applicable CMS Regional Office 
(RO) when it has accredited a provider or supplier under its CMS-approved Medicare 
accreditation program and is recommending the provider or supplier for deemed status.  
The RO forwards these notices to the applicable SA for inclusion in the certification kit 
that the SA subsequently forwards to the RO.  In initial certification cases where there is 
no AO notice of accreditation under a CMS-approved Medicare accreditation program for 
the applicant, SAs must not use other sources of information about the applicant being 
accredited to conclude that the applicant is deemed and must not enter deemed status 
for the applicant in ASPEN. 
 
An AO may not conduct an initial certification survey of a prospective provider or 
supplier for Medicare certification purposes until the MAC has completed its initial 
review of the enrollment application and has made a recommendation for approval to 
CMS.  CMS requires AOs subject to its oversight to employ a survey process that is 
comparable to the process required for an SA, which may not conduct an initial survey 
until it receives notice from the MAC recommending approval of the applicant (see 
Section 2003B).  Accordingly, an AO must also wait until the MAC has made its 
recommendation before it conducts an initial survey.  
 
The MAC gives the applicant written notice when its review has been completed.  
Therefore, AOs must inform providers or suppliers seeking to participate in Medicare via 
the AOs CMS-approved Medicare accreditation program that an initial, unannounced 
survey will not take place until after the applicant has received notice from the MAC that 
it has completed its review of the enrollment application and that the MAC is 
recommending approval.  If the MAC denies approval of the application, the AO must not 
proceed with a survey.  
 
Notices that the MAC provides to the SA and RO are internal communications among 
CMS and its contractors.   AOs are not entitled to receive copies of the MAC notice from 
the MAC, SA, or RO, but are expected to obtain copies of the MAC notice that was 
provided to the applicant. 
 
In the case of an applicant that is planning to acquire an existing Medicare-participating 
provider or supplier and that is considering rejecting assignment of the prior Medicare 
agreement, the AO must refer the applicant to the RO, so that the RO can provide detailed 
information on the consequences of acceptance or rejection of assignment.  In the case of 
an applicant that has acquired an existing Medicare-participating provider or supplier and 
has rejected assignment, the applicant is considered an initial applicant.  Generally, it is 
not acceptable for the AO to schedule an initial survey to minimize the period of time 
between the termination of the prior Medicare agreement and the effective date of the new 
agreement.   Surveys conducted either on the date an acquisition is effective or within 
days thereafter do not qualify as unannounced surveys and also are inconsistent with CMS 
regulations and policy that require such applicants to be treated in the same way as any 
other initial applicant.  See Section 3210 for more information about policies and 
procedures related to acquisitions of Medicare-participating providers or suppliers. 
  The AO is required to notify CMS whenever it newly accredits and recommends Medicare 
deemed status for a provider or supplier seeking Medicare participation.  This notice must 
be sent to both CO and the applicable RO via a designated email box (See Section 1022).  
However, the prospective provider or supplier must also provide the SA with 
documentation of the AOs accreditation decision and recommendation for deemed status.  
This documentation is included in and becomes part of the certification packet the SA 
submits to the RO.  Therefore, AOs must instruct the prospective provider or supplier to 
furnish a copy of this documentation to the SA for inclusion in the applicants certification 
packet. 
 
2004 - Provider-Based Determinations 
(Rev. 193, Issued: 09-20-19, Effective: 09-20-19, Implementation: 09-20-19) 
 
Distinct Part and Provider-Based are not synonymous terms.  When a location, 
department, remote location or satellite is established as being provider-based, it is an 
integral part of the provider, covered by the providers Medicare agreement, and therefore 
subject to the same Medicare conditions of participation as any other part of that provider.  
Unless covered by a specific exception listed in the rule, the provider-based regulations at 
413.65 apply to any provider of services under the Medicare program, as well as to 
physicians practices or clinics or other suppliers that are not themselves providers, but 
which the provider asserts are an integral part of that provider.   
 
Providers are not required to seek a determination from CMS that all of their provider-
based components satisfy the provider-based rules at 42 CFR 413.65, but they may 
voluntarily seek such determinations.  The RO Division of Financial Management makes 
provider-based determinations in response to a specific request.  If a provider requests the 
SA for a provider-based determination under the Medicare program for one or more of its 
component services, the SA must notify the RO immediately so that the request can be 
routed appropriately to the RO Division of Financial Management.  In the case of a 
request concerning an off-campus department, remote location or satellite, the providers 
survey and certification file about the locations included under its provider agreement 
must not be revised to add the new location until and unless the provider is issued a 
positive determination about its request.   
 
For Critical Access Hospitals (CAHs) adding a provider-based location  also see SOM 
Chapter 2, Section 2256H  Off-Campus CAH Facilities  Process Requirements. 
 
2005 - Medicare Health Care Provider/Supplier Enrollment 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect enrollment 
information in order to ensure that correct payments are made to providers and suppliers 
under the Medicare program established by Title XVIII of the Act for payment under Part 
A of Title XVIII [42 U.S.C. 1395f(a)(1) and 1395g(a)] and 1833(e) [42 U.S.C. 
13951(e)] for payment under Part B.  In addition, CMS is required to ensure that no 
payments are made to providers or suppliers who are excluded from participation in the 
Medicare program under 1128 of Title XVIII [42 U.S.C. 1320a-7], or who are  prohibited from providing services to the federal government under 2455 of the Federal 
Acquisition Streamlining Act of 1994 (P.L. 103-355) [31 U.S.C. 6101 note].  
 
The primary use of this information is to verify the eligibility of providers/suppliers to 
participate in the Medicare program, which will more effectively prevent fraud and abuse.  
The protocol that CMS uses to ensure that providers/suppliers meet these requirements is 
referred to as the enrollment process.  The enrollment process is also to be used for 
providers/suppliers that plan to seek certification for participation in Medicare based on 
deemed status through a CMS-approved Medicare accreditation program.  An applicant 
must complete the enrollment application process in order for CMS to obtain certain 
required information before a certification survey is conducted or, in the case of an FQHC, 
the RO countersigns the self-attestation. 
 
Providers/suppliers should be informed of the enrollment and certification process so that 
they do not have unrealistic expectations about the effective date of their provider or 
supplier agreement with Medicare, e.g., an applicant should not expect its effective date to 
be the date it submitted its enrollment application.  Should the applicant have any 
questions concerning the enrollment process form, it should be referred to the following 
Web site:  http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/index.html. 
 
The Medicare enrollment process is not applicable to the Medicaid program.  State 
Medicaid Agencies use their own enrollment process. 
 
2005A - Approval or Denial 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
2005A1 - Enrollment Denial Based on MAC Review 
 
When the MAC determines, after reviewing the Form CMS 855 application, that 
an applicant has failed to meet the enrollment process requirements, the MAC will 
issue a written denial to the applicant.   The RO is not involved in the issuance of 
the denial or in the processing of any request by the applicant for reconsideration 
or appeal.  Reconsideration requests or appeals are handled by the Center for 
Program Integrity Provider Enrollment Operations Group in the CO. 
 
Additionally, when an applicant is denied enrollment by the MAC, no survey is 
conducted. 
 
2005A2 - Approval or Denial of Certification Based on Survey Findings 
 
The SA (or RO, when applicable  all references below to SA surveys also apply to 
surveys conducted by the RO), surveys applicants that are subject to an on-site 
certification survey after it receives the recommendation of approval from the MAC, 
unless the applicant has the option of participation via deemed status (See Sections 2003C 
and 2005A4).  Additionally, the applicant must be operational and providing care to 
patients/residents in order for a certification survey to be conducted.  (See Section 2008A.)   All surveys are unannounced.   
 
Applicant in Compliance - The SA surveys the applicant and certifies or recommends 
Medicare approval if it determines that the applicant is in compliance with all conditions 
of participation/coverage/certification or requirements, as applicable.  (See Section 2008D 
for more information on the circumstances under which the SA certifies the applicant is or 
is not in compliance.)  The SA forwards the survey results and certification kit to the RO 
which determines whether and when all Federal requirements have been met by the 
applicant.  If all Federal requirements have been met, the RO proceeds with the providers 
or suppliers Medicare participation approval.  (In the case of HHAs, there is a 
requirement for the MAC to conduct a second verification of the enrollment information 
after the SA or accrediting organization survey is completed.  However, a second MAC 
review that takes place after the on-site certification survey will only delay the effective 
date of the HHAs Medicare agreement if that review identifies noncompliance with any 
Federal requirements.  If the HHA is found upon a post-survey second MAC review to 
continue to meet all requirements, there would be no change in the initial certification 
effective date previously provided by the MAC to the RO.  However, if the MAC finds the 
HHA does not meet all Federal requirements during the second review, there would be a 
delay in the effective date of any provider agreement that might eventually be issued to the 
HHA applicant until all requirements are determined to be met.) 
 
The RO will issue a provider or supplier agreement with an effective date, and assign a 
CMS Certification Number (CCN).  (See Section 2008.)  The RO will notify the MAC of 
the applicants approval for participation in the Medicare program by sending the Provider 
Tie-In Notice (Form CMS-2007), and/or a copy of the approval letter that will include the 
CCN.  The RO will send the SA a copy of the applicants approval letter. 
 
Applicant Not in Compliance  The SA surveys the applicant and certifies that the 
applicant is not in compliance with the conditions of participation/coverage/certification 
or requirements, as applicable.  (See Section 2008D for more information on the 
circumstances under which the SA certifies the applicant is or is not in compliance.)  The 
SA forwards the survey results to the RO, which will send the provider/supplier a denial 
letter.  The RO will forward a copy of the denial letter to the MAC and to the SA.  Claims 
will not be paid if the applicant is not approved through both the enrollment and the 
survey and certification processes.  
 
The applicant is issued a denial letter for noncompliance with the conditions of 
participation/coverage/certification.  The applicant may correct the deficiencies and 
reapply for certification.  The applicant who reapplies for certification must undergo a new 
survey which is a full, standard survey, except: 
 
  If on the first survey an applicant subject to the Life Safety Code (LSC) 
requirements was in substantial compliance with the LSC, the SA has the 
discretion to not resurvey for LSC compliance (although it must receive an 
acceptable Plan of Correction for any lower-level LSC deficiencies before it may 
recommend certification); and 
    In the case of an applicant seeking to participate as a hospital, the SA has the 
discretion to conduct a new survey of only those conditions for which the applicant 
was found non-compliant during the prior survey.  If the SA chooses to conduct 
such a focused subsequent survey, the hospital applicant must submit an 
acceptable plan of correction for all noncompliance identified in the prior survey, 
including for conditions where there were only lower-level deficiencies cited, 
before the SA may conduct the subsequent survey.   
 
NOTE:  It is not possible for an initial applicant to seek CAH status; the applicant 
must first be certified as a hospital, and then subsequently the hospital may apply 
to convert to CAH status.  This is technically a conversion, not an initial 
application.  If the SA certifies that the CAH applicant is not in compliance, then 
the RO sends a letter denying the hospitals request to convert to CAH status.  
Unless the denial was based on the applicant not satisfying the CAH location 
requirements, the applicant may seek to be surveyed again for CAH conversion.  
As with initial hospital applicants, the SA has the discretion to conduct a new 
survey of only those conditions for which the CAH applicant was found non-
compliant during the prior survey.  If the SA chooses to conduct such a focused 
subsequent survey, the CAH applicant must submit an acceptable plan of 
correction for all noncompliance identified in the prior survey, including for 
conditions where there were only lower-level deficiencies cited, before the SA 
may conduct the subsequent survey. 
 
In all cases the RO retains the authority to require a new full survey if it has concerns 
about a certification recommendation based on a focused survey after a prior survey 
identified substantial noncompliance.  In cases where the RO anticipates that it will 
require a new full survey, it should notify the SA of this as soon as possible, to facilitate 
planning for the full survey by the SA. 
 
If the SA continues to find the applicant is not in compliance with the conditions of 
participation/coverage/certification or requirements, as applicable, on the subsequent 
survey, the above process may be repeated.  However: 
 
  The applicant may submit no more than two reapplications for certification in 
connection with one enrollment application; and  
 
  No more than six months may elapse between the date of the ROs first denial of 
certification and receipt by the RO of a second reapplication for certification (for a 
total of three certification applications).   
 
If the applicant fails to demonstrate compliance by the end of this six month period, the 
RO not only issues a final denial of certification, but also sends a written recommendation 
to the MAC that the enrollment application be closed out as denied.  If the applicant 
continues to seek enrollment and certification, the RO must receive a new MAC 
recommendation for approval before it may process a new certification application. 
 
2005A3 - Reconsideration of Denial   
Procedure for Reconsideration - An applicant has the right to request a reconsideration of 
an initial certification denial decision.  See Chapter 3, Sections 3050  3054 for 
reconsideration procedures and timeframes.  Note that the RO may not simultaneously 
process a certification reapplication and a request for reconsideration.  However, in 
accordance with Section 3054A, the applicant may withdraw its reconsideration request 
and reapply for certification if it has corrected the deficiencies identified on the survey. 
 
2005A4  Deemed Providers/Suppliers, Excluding CLIA 
 
Initial Survey by an AO with a CMS-Approved Medicare Accreditation Program 
 
The AOs CMS-approved Medicare accreditation program must provide reasonable 
assurance that providers or suppliers accredited by the AO meet all Medicare Conditions 
of Participation (CoPs) or Conditions for Coverage/Certification (CfCs), as applicable.  
CMS evaluates and reviews AOs seeking recognition of their accreditation programs for 
Medicare participation on a number of factors specified in 42 CFR 488.8, including the 
AOs accreditation standards, survey and oversight processes, and their comparability to 
CMS' standards and processes.  Furthermore, 42 CFR 489.13 governs how CMS 
determines the effective date of a providers or suppliers Medicare agreement or 
approval, including provisions related to certification survey findings. 
 
Accordingly, before the AO makes a recommendation to CMS that an applicant seeking 
initial certification and enrollment in Medicare be deemed to meet Medicares health 
and safety standards, the AO must conduct a survey and determine that the applicant 
meets all requirements for accreditation, including compliance with all applicable 
Medicare CoPs or CfCs.  
 
Applicant in Compliance 
 
If the applicant is found to comply with all accreditation requirements, the AO may award 
deemed status accreditation, effective no earlier than the accreditation survey end date, 
and recommend the applicant to the RO for Medicare certification via deemed status.  The 
AO must inform the applicant and the RO of the results of the initial accreditation survey 
and of its recommendation of the applicant for certification via deemed status, including 
the effective date of the applicants accreditation. 
 
If the applicant is found to be in substantial compliance, but has lower-level deficiencies, 
then the AO must receive an acceptable plan of correction (POC) for such deficiencies.  
(See Section 2008D.)  Once the AO receives an acceptable POC from the applicant, the 
AO may award deemed status accreditation and recommend the applicant for Medicare 
certification via deemed status.  The AO may not make the effective date of the 
applicants deemed status accreditation prior to the date of receipt of a POC that the AO 
finds acceptable.  The AO must inform the applicant and the RO of the results of the 
initial accreditation survey, the receipt of an acceptable POC, and its recommendation of 
the applicant for deemed status, including the effective date of accreditation.  The AO 
must also send its survey report to the RO.   
When the AO notifies CMS of an applicants accreditation and the AOs recommendation 
of deemed status for that applicant, the RO reviews the AOs accreditation survey report 
and other documentation.  If the RO accepts the AOs recommendation of deemed status, 
it forwards the AOs notice of accreditation and recommendation of deemed status to the 
SA.  The SA must prepare an initial certification packet for the provider or supplier.  The 
certification packet is sent by the SA to the RO, with the Medicare Health Insurance 
Agreement (Form CMS-1561, 1561A or 370, depending on provider/supplier type) 
submitted to the SA by the applicant, along with any other documentation required for 
initial certification of that provider/supplier type. (See Exhibit 63 for documentation 
requirements.)  In the remarks section of the Form CMS-1539, the SA indicates that it is 
transmitting an initial certification kit for an accredited, deemed provider/supplier.  Once 
the RO receives the certification packet, it proceeds as described in Section 2005A2.  The 
RO must send to the AO in a timely manner a copy of its approval letter to the applicant.  
Among other things, the copy of the approval letter advises the AO of the CCN assigned 
to the new providers/suppliers Medicare agreement, facilitating the AOs ability to 
report accurate data to CMS on its deemed status providers/suppliers. 
 
If the ROs review of the accreditation survey suggests a problem, including, but not 
limited to: 
 
  the AOs survey report describes findings which represent substantial noncompliance 
with a Medicare condition, but the AO awarded accreditation anyway; or  
 
  the AOs survey report indicated the applicant was required to submit an acceptable 
POC for lower-level deficiencies, but the AO issued its accreditation effective on a 
date prior to its receipt of the POC; or 
 
  the AO conducted an extension survey but the applicant is a new owner that rejected 
assignment of the prior owners Medicare agreement and must therefore undergo a full 
accreditation survey; 
 
the RO may, consistent with 488.6(c)(2),  reject the AOs recommendation of deemed 
status.  In such cases the RO contacts the AO to discuss its concerns and ways the AO 
may remedy them, if possible.  If the problems are not remedied, the RO may issue a 
denial of certification to the applicant and provides a copy to the AO in a timely manner. 
 
Applicant Not in Compliance 
 
If the AO finds the applicants failure to meet its CMS-approved Medicare accreditation 
program requirements represents substantial noncompliance with accreditation standards, 
including applicable Medicare CoPs or CfCs, the AO may not recommend the applicant 
for Medicare certification via deemed status.  Rather, the AO must inform the applicant 
and the RO of the results of the initial survey and that it is not recommending the applicant 
for deemed status.  The RO issues a denial of certification based on the AOs information, 
and provides a copy to the AO in a timely manner.   
  The applicant may, at the AOs discretion, continue to work with the AO to correct the 
deficiencies and again seek initial certification through deemed status.  If the applicant is 
surveyed again by the AO the survey must be a new survey which is a full, standard 
survey, except: 
 
  If on the first survey an applicant subject to the Life Safety Code (LSC) 
requirements was in substantial compliance with the LSC, the AO has the 
discretion to not resurvey for LSC compliance (although it must receive an 
acceptable Plan of Correction for any lower-level deficiencies before it may 
recommend deemed status); and 
 
  In the case of an applicant seeking to participate as a hospital, the AO has the 
discretion to conduct a new survey of only those conditions for which the applicant 
was found non-compliant during the prior survey.   If the AO chooses to conduct 
such a focused subsequent survey, the hospital applicant must submit an 
acceptable plan of correction for all noncompliance identified in the prior survey, 
including for conditions where there were only lower-level deficiencies cited, 
before the AO may conduct the subsequent survey. 
 
NOTE:  It is not possible for an initial applicant to seek CAH status; the applicant 
must first be certified as a hospital, and then subsequently the hospital may apply 
to convert to CAH status.  This is technically a conversion, not an initial 
application.  If the AO advises CMS that it is not recommending the applicant for 
CAH deemed status or if the RO determines that the applicant does not satisfy the 
CAH location requirements, then the RO sends a letter denying the hospitals 
request to convert to CAH status.  Unless the denial was based on the applicant not 
satisfying the CAH location requirements, the applicant may, at the AOs 
discretion, continue to work with the AO to correct the deficiencies and again seek 
CAH certification through deemed status.  As with initial hospital applicants, the 
AO has the discretion to conduct a new survey of only those conditions for which 
the CAH applicant was found non-compliant during the prior survey.  If the AO 
chooses to conduct such a focused subsequent survey, the CAH applicant must 
submit an acceptable plan of correction for all noncompliance identified in the 
prior survey for all noncompliance identified in the prior survey, including for 
conditions where there were only lower-level deficiencies cited, before the AO 
may conduct the subsequent survey.   
 
In all cases the RO retains the authority to require a new full survey if it has concerns 
about a deemed status recommendation based on a focused survey after a prior survey 
identified substantial noncompliance.  In cases where the RO anticipates that it will 
require a new full survey, it should notify the AO of this as soon as possible, to facilitate 
planning for the full survey by the AO. 
 
If the AO continues to find substantial noncompliance on the subsequent survey, the 
above process may be repeated.  However: 
 
  The applicant may submit no more than two reapplications for certification in  connection with one enrollment application; and  
 
  No more than six months may elapse between the date of the ROs first denial of 
certification and receipt by the RO of a second reapplication for certification (for a 
total of three certification applications).   
 
If the applicant fails to demonstrate compliance by the end of this six month period, the 
RO not only issues a final denial of certification, but also sends a written recommendation 
to the MAC that the enrollment application be closed out as denied.  If the applicant 
continues to seek enrollment and certification, the RO must receive a new MAC 
recommendation for approval before it may process a new certification application. 
 
2005B - Deemed Providers/Suppliers Except CLIA  Additional 
Information 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
AO renewal of deemed provider/supplier accreditation:  
 
AOs conduct re-accreditation surveys of Medicare-deemed providers and suppliers on a 
triennial basis.  Upon awarding re-accreditation, the AO also makes a recommendation for 
the providers or suppliers continued Medicare deemed status.  The providers or 
suppliers deemed status continues without interruption. 
 
When the AO notifies CMS of its renewal of accreditation and recommendation of 
continued deemed status, the RO forwards the notice to the SA and the SA must prepare a 
recertification kit for the provider or supplier.  The recertification packet is sent by the SA 
to the RO, with the Form CMS-1539 and any other documentation required for that 
provider/supplier type. (See Exhibit 63 for documentation requirements.)  In the remarks 
section of the Form CMS-1539, the SA indicates it is transmitting an accredited, deemed 
provider/supplier update. 
 
Termination/Withdrawal; Removal of Deemed Status 
 
The AO must notify CMS whenever a providers or suppliers accredited status is not 
renewed, as well as the reason for the loss of accreditation.  If the AO notifies CMS that 
the AO has terminated a providers or suppliers accreditation, or that the provider or 
supplier has voluntarily withdrawn from the AOs CMS-approved Medicare accreditation 
program, the RO must remove the providers or suppliers deemed status, unless there is 
evidence of accreditation under another CMS-approved Medicare accreditation program.  
For example, if the provider or supplier was accredited simultaneously under two CMS-
approved programs, and one AO notifies CMS of a termination or withdrawal, the 
provider/supplier would continue to have deemed status based on the other accreditation.  
However, if the notice of termination by the first AO indicates that the reason for 
termination was the providers/suppliers failure to meet accreditation standards, the RO 
must consider this a substantial allegation of noncompliance with Medicare standards and 
must authorize the SA to conduct a complaint investigation. 
  If one AO provides notice of termination or withdrawal and concurrently another AO 
recommends deemed status, a recertification packet including the new AO 
recommendation must be submitted by the SA to the RO.  (See also Section 3258.) 
 
If the RO removes the providers or suppliers deemed status, it places the 
provider/supplier under the jurisdiction of the SA and must advise the SA of the change in 
the providers/suppliers status.  The SA surveys the facility in order to provide assurance 
that the facility is in compliance with the applicable Medicare conditions.  The timing of 
the SA survey depends on the reason for the providers/suppliers loss of accreditation:  
 
  If the AO terminates accreditation due to failure of the provider/supplier to meet 
accreditation standards, then the SA must conduct a standard survey within 45 
calendar days of notification by the RO that deemed status has been removed.  If 
the AOs reason for termination appears to be related to an immediate jeopardy, 
then the RO instructs the SA to conduct the standard survey as soon as possible. 
 
  If the AO terminates accreditation due to voluntary withdrawal or failure to pay 
fees by the provider/supplier, the SA prioritizes the providers/suppliers survey on 
the basis of the current CMS policy concerning survey frequencies and SA 
workload priorities, using the date of the most recent accreditation survey to 
calculate the survey interval, unless: 
 
   The facility is a home health agency (HHA). Then the SA must conduct the 
survey no later than 3 years after the last accreditation survey; or 
 
  The RO exercises its discretion to request the SA to conduct the survey by a 
specified date.  
 
CMS may also temporarily remove deemed status (and therefore AO jurisdiction) when a 
SA or Federal survey team identifies condition-level non-compliance in a deemed 
provider or supplier during either a representative sample or substantial allegation 
validation survey.  The RO advises the provider or supplier that its deemed status is 
removed and that it is being placed under SA jurisdiction.  However, no change is made to 
the providers or suppliers deemed status in the Automated Survey Process Environment 
(ASPEN).  Instead, the placement of the provider or supplier under SA jurisdiction is 
noted under the Deeming tab within the certification kit in ACO. 
 
The provider/supplier remains under SA jurisdiction until it either demonstrates 
substantial compliance or CMS terminates its Medicare participation. If the 
provider/supplier demonstrates substantial compliance to the SA, CMS restores its deemed 
status.  Note that there is no prohibition against an AO also conducting its own survey of a 
provider/supplier that is temporarily under SA jurisdiction. 
 
Other AO adverse actions 
 
The AO is required to inform CMS of significant adverse actions it takes against the 
accreditation status of a provider/supplier participating through deemed status.  However,  as long as the accreditation under the AOs CMS-approved Medicare accreditation 
program is not terminated, the provider/supplier's participation in Medicare is not affected.  
See Section 3258 for information on actions to take when an AO terminates the 
accreditation of a deemed provider or supplier.  
 
The AO is also required to inform CMS by close of business the next day when it 
identifies an immediate jeopardy situation on a survey.  In such cases, the RO generally 
triages this as an immediate jeopardy complaint and directs the SA to conduct a 
substantial allegation validation survey, based on the information provided by the AO. 
 
2005C - Clinical Laboratory Improvement Amendments of 1988 (CLIA) 
Laboratories 
(Rev. 1, 05-21-04) 
 
The procedures for initial certification basically apply to CLIA laboratories with a few 
exceptions. The enrollment procedures for CLIA laboratories are outlined as follows. 
CLIA laboratories will be surveyed (if applicable) and registered for CLIA participation 
whether or not the laboratory enrolls in Medicare. The enrollment Form CMS-855A or 
CMS-855B process applies to all CLIA laboratories that participate in Medicare. This 
includes laboratories that have a certificate of waiver, certificate for physician performed 
microscopy procedures, certificate of accreditation, certificate of compliance, certificate of 
registration, or are state exempt. However laboratories that bill through the fiscal 
intermediary (are part of a Part A institutional provider, such as a hospital or SNF) will not 
need to complete the Form CMS-855A or CMS-855B. 
 
The Form CMS- 855A or CMS-855B will be downloaded from the CMS Web site - 
http://www.cms.hhs.gov/forms/ and completed by the CLIA laboratory. The SA will mail 
out Form CMS-116, and any other form needed for CLIA registration to the laboratory. A 
CLIA laboratory is only required to complete a Form CMS-855A or CMS-855B if it 
decides to enroll in Medicare. At the time a laboratory initially applies for CLIA 
registration, inquire as to whether the laboratory intends to bill Medicare. 
 
If the laboratory intends to bill Medicare, send the laboratory Form CMS-116 and Form 
CMS-855A or CMS-855B. Questions on the Form CMS-855A or CMS-855B, form 
should be addressed to the intermediary/carrier. The SA will send the laboratory the Form 
CMS-116. The laboratory will complete and return the Form CMS-116 to the SA and the 
Form CMS-855A or CMS-855B to the FI or Carrier. The SA will enter the Form CMS-
116 into the CLIA data system, and the system will assign a CLIA number to the 
laboratory. For CLIA laboratories, the intermediary/carrier will be responsible for all 
aspects of the Form CMS-855A or CMS-855B and Medicare enrollment processing. After 
the intermediary/carrier has reviewed and verified the Form CMS-855A or CMS-855B, it 
will send a completed copy of the Form CMS-855A or CMS-855B to the RO and State 
survey agency along with its recommendation for approval or denial. (See 2005.A) for 
instructions regarding approvals, denials and appeals.)  Processing of the Form CMS-
855A or CMS-855B will not affect the scheduling of CLIA surveys since CLIA 
registration must occur regardless of Medicare enrollment. If a laboratory is denied for 
Medicare, follow the instructions for denials and take all appropriate CLIA-related  actions. 
 
If the laboratory does not plan to bill Medicare, it should complete Forms CMS-116 and 
return it to the State survey agency.  
 
2005D - Supplementary Applications 
(Rev. 1, 05-21-04) 
 
An additional application used for supplementary purposes to support the Form CMS-
855A or the CMS-855B is The Medicare Individual Reassignment of Benefits Health Care 
Provider/Supplier Application (Form CMS-855R). The Medicare Change of Information 
Health Care Provider/Supplier Application (Form CMS-855C) is no longer used. The 
CMS-855A or the CMS-855 B is used to report changes to enrollment (see also 2003).  
The fiscal intermediary/carrier will send a copy of the Form CMS-855A or CMS-855B 
with the updated/changed information to the appropriate State Agency and RO.  
 
2005D1 - Forms CMS-855A or the CMS-855B for Changes in 
Provider/Supplier Information 
(Rev. 1, 05-21-04) 
 
Application changes are changes to any items on the Form CMS-855A or CMS-855B. 
These changes require the submission of the appropriate updated sections of the Form 
CMS-855A or CMS-855B with a signed certification statement. The changes will be 
reviewed by the fiscal intermediary/carrier. The review will result in a recommendation 
for approval, denial, or return for additional information. The fiscal intermediary/carrier 
will send a copy of the Form CMS-855A or CMS-855B with the updated/changed 
information to the State agency or RO that distributed the initial application. 
 
When a provider experiences a change of ownership the current owner will check the box 
marked potential termination of current ownership on the Form CMS-855A or CMS-
855B. 
 
Voluntary use of the Form CMS-855A or CMS-855B is encouraged for 
providers/suppliers that were previously certified without completing the Form CMS-
855A or CMS-855B. However, these providers/suppliers may submit these changes in 
writing on letterhead with an authorized signature. 
 
2005D2 - Form CMS-855R 
(Rev. 1, 05-21-04) 
 
In general, Medicare only makes payments to the individual or entity that directly 
provides services. However, an individual may reassign benefits to an eligible entity as 
defined in 42 CFR 424.80. This application must be completed when an individual 
practitioner is reassigning his/her benefits to an eligible entity. An eligible entity is a 
business organization that is eligible to receive reassigned benefits (e.g., employer, 
facility, health care delivery system or agent).  Not every provider/supplier will need to 
complete the Form CMS-855R. Organizations that are likely to receive reassigned benefits  are: hospitals, hospices, SNF, ESRD, RHC, CORF, FQHC, and CMHC.  
 
The Form CMS-855R is available to applicants for downloading via the CMS Web site at 
http://www.cms.hhs.gov/forms/. The State survey agency should inform the applicant that 
any questions concerning the Form CMS-855R should be directed to the intermediary or 
carrier. If the State agency receives the Form CMS-855R, it will forward the Form CMS-
855R to the intermediary.  After reviewing the application and making a recommendation, 
the intermediary will forward the package to the carrier for the carriers review of the 
reassignment of benefits. 
 
2005E - Changes of Ownership 
(Rev. 1, 05-21-04) 
 
See 3210 for a full discussion of change of ownership (CHOW).  The following 
procedures apply to all provider/supplier types that are subject to survey and/or 
certification. 
 
2005E1 - CHOW Occurs  
(Rev. 1, 05-21-04) 
 
For a CHOW, the current owners will submit a Form CMS-855A or CMS-855B citing the 
termination of current ownership. The current owner will check the box marked potential 
termination of current ownership on the Form CMS-855A or CMS-855B and complete 
Section 1 (Provider/Supplier Information), Section 8 (Potential Termination of Current 
Ownership), and Section 10 (Attestation Statement).  The new owners will complete and 
submit a new Form CMS-855A or CMS-855B. 
 
The current and new owners will submit the Form CMS-855A or Form CMS-855B along 
with any supporting documents to the FI or carrier. The RO has the delegated authority for 
making the determination if a CHOW actually exists.  [However, the RO may delegate 
this responsibility to the State agency.]  For complex or questionable situations, the 
FI/carrier will forward all documents to the RO for review. Upon review of all documents, 
the RO will make the decision as to whether or not a CHOW has occurred.  The 
intermediary/carrier will verify the Forms CMS-855A or CMS-855B and may take one of 
three actions on a CHOW:  
 
  Recommendation for approval;  
 
  Recommend for denial; or 
 
  Request for additional information. 
 
Verification of Information From Intermediary/Carrier - After a complete review and 
verification of the application, if no additional information is needed, and there is no need 
to issue a denial, the intermediary/carrier notifies the RO/SA of its verification of 
information provided about the CHOW within 30 calendar days (absent extenuating 
circumstances) of the receipt of the completed enrollment applications. The notification  will be written and accompanied by a copy of the completed Forms CMS-855A or 
CMS-855B, if any changes were made to the forms. 
 
RO Determines CHOW Has Occurred - If the RO determines that a CHOW has 
occurred, the RO waits until it receives the intermediary/carriers verification of 
information about the CHOW before completing the process.  When the process is 
completed, the RO will notify the provider/supplier, State agency and intermediary/carrier 
that a CHOW has occurred. 
 
RO Determines CHOW Has Not Occurred - The RO makes the final decision whether 
a CHOW has actually occurred. If the RO determines that a CHOW has not occurred, the 
RO notifies the provider/supplier, the State survey agency, and the intermediary/carrier 
that a CHOW has not taken place.  The notification should explain the reason(s) why a 
CHOW has not occurred. 
 
Recommendation for Denial from Intermediary/Carrier - After a complete review and 
verification of the application, the intermediary/carrier may recommend a denial of the 
Form CMS-855A or Form CMS-855B based on one or more of the reasons for denial 
stated in 2005.A.3.  The intermediary/carrier will send the recommendation of denial to 
the RO/SA. 
 
For a CHOW, the provider agreement may be automatically assigned to the new owner.  
However, the new owner could choose to come into Medicare as a new applicant and 
should be advised of this option.  In such a case if the new owner accepts the assignment it 
also assumes the former owners liabilities.  (The new owner could also receive an 
outstanding underpayment under this scenario).  The new owner must enroll the same as 
any other new applicant (see 3210), undergo the survey and certification process, and be 
issued a new provider agreement/number.  The RO/SA processes a voluntary termination 
of the provider agreement of the former owner. 
 
2005E2 - Change in Intermediary as Result of CHOW 
(Rev. 1, 05-21-04) 
 
Providers who are changing their intermediary as a result of a CHOW, acquisition, 
merger, or consolidation should submit the information to the new intermediary of 
preference.  This information, which is required to be submitted by Form CMS-855A, 
should be promptly processed by the new intermediary.  However, the provider should 
also request a change of intermediary from the RO.  If an FI receives a Form CMS-855A 
for a CHOW that requires a change of intermediary, it should contact the provider and 
advise it to contact the current RO for a change of intermediary.  The new intermediary 
shall contact the outgoing intermediary and provide it with the submitted information.  If 
the provider mistakenly submits the CHOW information to the old intermediary, the old 
intermediary shall contact the new preferred intermediary and forward the submitted 
information to it.  The new intermediary shall note on any recommendation for approval if 
a required change of intermediary request has not yet been approved by the RO. 
 
NOTE:  CHOW determinations are the responsibility of the RO unless otherwise  delegated. 
 
2005E3 - CHOWs Involving Multi-Regional Chain Organizations 
(Rev. 1, 05-21-04) 
 
When a CHOW involves a multi-regional chain organization, a lead or coordinating RO is 
designated.  This will typically be the RO serving the State in which the headquarters of 
the chain doing the acquiring is located. The coordinating RO will notify all other affected 
ROs and intermediaries involved in the CHOW determination and processing of 
enrollment activities. The lead RO may decide which intermediary(ies) will process the 
new CHOW applications.  A separate Form CMS-855A is still required for each 
separately surveyed provider/supplier. However, they all may be processed simultaneously 
by the receiving intermediary when the incoming chain requests one intermediary for all 
the units. Each intermediary shall follow the instructions of the lead RO for CHOWs 
involving multi-regional chains. 
 
For a CHOW which involves multiple incoming or multiple outgoing intermediaries 
handled by the same RO, the RO shall also direct where and how the new application 
should be reviewed, and serve as the coordinator for the CHOW in a manner similar to 
being the lead RO for a multi-regional CHOW. 
 
2005E4 - Change of Owners, but Not CHOW 
(Rev. 1, 05-21-04) 
 
A partnership provider sometimes experiences an addition or deletion of personnel, but a 
CHOW does not occur. For example, a provider may add or delete owners without 
experiencing a CHOW.  In these situations, the provider should complete section 10 
(Ownership Information) on the Form CMS-855A or CMS-855B.  It should also complete 
identifying information in section 1 (Applicant Information) and section 19 (Certification 
Statement).  The rest of the form does not need to be completed. Advise the 
provider/supplier to submit the Form CMS-855A or CMS-855B directly to the 
intermediary/carrier. The intermediary/carrier will send a copy of the Form CMS-855A or 
CMS-855B to the SA/RO when it has completed its verification. 
 
In certain situations, based on the review of a submitted Form CMS-855A or CMS-855B, 
the intermediary/carrier may suspect that a CHOW has occurred that the RO may not be 
aware of.  In these cases, the intermediary/carrier may notify the State survey agency and 
RO and request a determination.  The intermediary/carrier will send a letter to the State 
survey agency and RO, along with a copy of the Form CMS-855 or CMS-855B and any 
supporting documentation.  The RO will determine whether a CHOW has actually 
occurred and report its findings to the intermediary and the State survey agency. 
 
2005F - Voluntary Terminations 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
A provider agreement may be voluntarily terminated in accordance with the regulations at 
42 CFR 489.52.  The provider must send written notice of its intention, a letter on  letterhead with an authorized signature, to its RO or SA within the timeframes addressed 
in 489.52.  Suppliers must provide notice in accordance with the regulatory requirements 
specific for the supplier type. 
 
Additionally, a provider/supplier must properly complete and submit the applicable Form 
CMS-855A or CMS-855B to the MAC.  If the provider/supplier sends the Form CMS-
855A or CMS-855B for voluntary termination directly to the MAC, then the MAC will 
notify the RO and SA via email within three days from the receipt of the completed form.   
 
NOTE: In a change of ownership situation, the rejection of automatic assignment of the 
existing provider/supplier agreement (by the new owner) is a voluntary termination of the 
agreement/approval, including its associated CCNs, in accordance with 42 CFR 489.52.  
 
Further, if the new owner rejects automatic assignment of the acquired facilitys existing 
provider/supplier agreement, and that facility previously was deemed to meet the 
applicable conditions based on its accreditation under a CMS-approved Medicare 
accreditation program, the accrediting organization (AO) may not extend the facilitys 
prior deemed status to the new owner. Instead, the AO must conduct a full initial 
accreditation survey of the facility under its new ownership after the acquisition date. The 
effective date of the new owners Medicare provider agreement or supplier approval is 
established in accordance with the provisions of 42 CFR 489.13. For complete 
information on CHOWs, see SOM 3210. 
 
NOTE: A cessation of business is a voluntary termination under 42 CFR 489.52(b)(3). 
 
2008 - Prioritizing SA Survey Workload - Initial Surveys and 
Recertifications 
(Rev. 1, 05-21-04) 
 
2008A - Surveys of New Providers and Suppliers 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
New providers/suppliers, including providers/suppliers whose previous Medicare 
agreement was terminated and are now seeking initial certification, must be in full 
operation and providing services to patients when surveyed.  This means that at the time 
of survey, the institution must have opened its doors to admissions, be furnishing all 
services necessary to meet the applicable provider or supplier definition, and demonstrate 
the operational capability of all facets of its operations.  To be considered fully 
operational, initial applicants must be serving a sufficient number of patients so that 
compliance with all requirements can be determined. 
 
A survey evaluates the manner and degree to which the provider or supplier satisfies the 
various requirements or standards within each condition.  Surveyors must directly observe 
the provision of care and services to patients, and the effects of that care, in addition to 
interviewing staff and patients and reviewing medical records to assess whether the care 
provided meets the needs of individual patients and is in compliance with all 
requirements.  Surveyors also review selected provider/supplier policy and procedure  documents if needed to support or clarify observations suggesting deficiencies.   
  
When the provider/supplier notifies the SA of full operation, the SA documents the file 
with the date of notification.  The SA conducts the survey in a timeframe consistent with 
CMS policy regarding budget and workload priorities. 
 
2008B - Initial Surveys of HHAs 
(Rev. 1, 05-21-04) 
 
In addition to an onsite survey to determine compliance with the health and safety 
conditions of participation (CoP), an HHA applicant must now meet capitalization 
requirements, and complete the enrollment information contained on the Form CMS-855A 
or CMS-855B, which includes the HHAs ownership information.  Also, the Centers for 
Medicare & Medicaid Services (CMS) is now requiring each HHA applicant to have 
provided skilled home health services to a minimum of 10 patients before a survey is 
conducted.  At least 7 of the 10 required patients should be receiving care from the HHA 
at the time of the initial Medicare survey. 
 
2008D - Effective Date of Medicare Provider Agreement or Approval for 
Suppliers 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
In accordance with 42 CFR 489.13, the effective date of participation in the Medicare 
program, i.e. the effective date indicated on the provider or supplier agreement issued by 
the RO, may not be earlier than the date on which the provider or supplier meets all 
federal requirements.  Federal requirements include, but are not limited to: 
 
  Meeting all Medicare enrollment requirements addressed in 42 CFR 424; 
 
  Meeting all Medicare provider agreement requirements addressed in 42 CFR 489.10 
and 42 CFR 489.12, and; 
 
  Compliance with Medicare health and safety standards, i.e., the Conditions of 
Participation, Conditions for Coverage, Conditions for Certification, or long term care 
Requirements, as applicable.  
 
  For an agreement with a federally qualified health center (FQHC), no survey is 
required to determine compliance.  The effective date is the date on which CMS 
accepts a signed agreement in which the FQHC attests that it meets all Federal 
requirements.  For FQHCs, the RO uses as the effective date of the supplier 
approval the date that the MAC indicates it determined that the FQHCs 
enrollment application was complete and approvable.   
 
  A Medicare supplier approval of a laboratory is effective only while the laboratory 
has in effect a valid CLIA certificate issued under 42 CFR Part 493, and only for 
the specialty and subspecialty tests it is authorized to perform. 
    Other types of providers and suppliers demonstrate compliance with applicable 
conditions or requirements via a standard survey by the SA (or Federal 
surveyors/contractors), or by an AO with a CMS-approved Medicare accreditation 
program. 
 
  If on that survey the provider or supplier meets all health and safety standards 
(including elements, where applicable), then the effective date of the Medicare 
agreement is the last day of the survey, unless there are other Federal 
requirements, such as providing evidence of compliance with Civil Rights 
requirements, that the provider or supplier has not yet met.  The date when all 
other Federal requirements have been met is the effective date of the Medicare 
agreement. 
 
  If on that survey the provider or supplier does not meet all health and safety 
standards (including elements, if applicable), then, assuming all other Federal 
requirements have been met, the effective date of the Medicare agreement 
would be:  
 
  For SNFs, the date the SNF has been found to be in substantial 
compliance with the requirements for participation, and, if applicable, 
has submitted an approvable waiver request. (See 42 CFR 488.301.)  
 
  For non-long term care providers/suppliers, the date when the 
provider/supplier has: 
 
  Met all applicable conditions; or 
 
Has been found to be in substantial compliance, but has standard-level (or element-level, 
where applicable) deficiencies and the RO (in the case of surveys conducted by 
contractors), SA or AO has received an acceptable plan of correction (POC) and/or CMS 
receives an approvable waiver request.  If a provider or supplier submits both a POC and 
an approvable waiver request, the later of the dates of the two submissions would be the 
effective date. 
 
2008E - Administrative Considerations  
 
(Rev. 1, 05-21-04) 
 
The SA will schedule more frequent surveys and follow-up visits for providers and 
suppliers with a history of poor performance.  Keep in mind geographical considerations 
and the scheduling of licensure visits and coordinate visits whenever possible.  Changes of 
Ownership (CHOWs) may necessitate adjustment of the survey interval.  (See 2702.) 
 
2008F - SA Scheduling of Resurveys 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Sections 1819(g)(2)(A)(iii) and 1919(g)(2)(A)(iii) of the Act require that each SNF and  NF respectively be subject to a standard survey no later than 15 months after the previous 
standard survey and that the state-wide average interval between such surveys not exceed 
12 months.  Section 1891(c)(2)(A) requires that each HHA be subject to a standard survey 
within a 36-month interval.  Since the law also prohibits the announcing of such surveys, 
utilize flexible survey schedules to ensure that these surveys are as unpredictable as 
possible. (Sections 1819(g)(2)(A)(i), 1919(g)(2)(A)(i), and 1891(c)(1) of the Act establish 
civil money penalties (CMPs) for any individual who notifies a SNF, NF, or HHA of a 
survey.)  A facility should not be surveyed during the same month each year.  The SA may 
conduct surveys of these providers as frequently as it deems necessary, but no more than 
15 months after the last standard survey of any SNF or NF, or 36 months for any HHA.  
 
In developing the SA survey schedule for HHAs, SNFs, and NFs (at a minimum), the SA 
utilizes information from SA files, the Online Survey Certification and Reporting System 
(OSCAR), and other sources at its disposal to identify those providers with poor 
performance records who should be resurveyed more frequently.  Conversely, the SA 
utilizes the same information to identify those providers that have established a history of 
good performance, who could be resurveyed less frequently.  (See 2702.) 
 
For example, the SA may find that some facilities should be resurveyed within 4 months 
of the prior standard survey, while others may not require a resurvey for up to 15 months 
from the prior standard survey.  The statewide average for SNFs and NFs may not exceed 
12 months in a given Federal fiscal year.  Schedule surveys to provide a cushion against 
any unforeseeable events, such as staff turnover.  Section 1891(c)(2)(B)(ii) of the Act also 
requires conducting a standard survey (or abbreviated standard survey) of any HHA 
against which a significant number of complaints have been reported.  Sections 
1819(g)(2)(A)(iii), 1919(g)(2)(A)(iii), and 1891(c)(2)(B)(i) of the Act also state that such 
surveys of SNFs, NFs, and HHAs may be conducted within 2 months of any change in 
ownership, administration, management, and (for SNFs and NFs) director of nursing 
(DON) to determine whether the change has caused any decline in the quality of care 
furnished.  
 
Based on documented evidence of current accreditation, the SA recertifies accredited 
entities on a schedule consistent with their accreditation interval.  For example, for 
hospitals, that interval may be only every three years.  
 
The timing of the Life Safety Code (LSC) survey is at the discretion of the SA.  It may 
occur before, after, or simultaneously with the health portion of the survey.  (See 7410 
for more guidance on LSC for SNFs and NFs.) 
 
2010 - Ascertaining Compliance With Civil Rights Requirements 
(Rev. 53; Issued:  10-16-09; Effective/Implementation Date:  10-16-09) 
 
Before an agreement is executed with a provider to participate in the Medicare program or 
with a provider undergoing a change in ownership (CHOW), there must be a 
determination of compliance with civil rights requirements.  OCR conducts necessary 
investigations and makes determinations related to compliance with the requirements.  If 
the RO cannot secure an OCR clearance within 20 calendar days, it issues a restricted  provider agreement with a contingency clause, which states that if OCR approval is not 
obtained, payment will be recouped as of the date the provider agreement is effective. 
 
The SA provides potential providers with the required OCR Civil Rights Certification 
Information Request Packet (Packet) for clearance.  The SA collects the completed Packet 
(including the signed questionnaire, signed HHS-690 form, and policies and procedures) 
from potential providers and forwards them to the RO. 
 
SAs should take the following steps: 
 
  Include the Packet with the initial enrollment package that is sent to a potential 
provider or to a provider undergoing a CHOW;  
 
  Ask the potential provider or provider undergoing a CHOW to return the 
completed signed questionnaire, HHS-690 Form, and civil rights policies and 
procedures to the SA with the rest of the Medicare application package;  
 
  Ensure that completed OCR documents are included in the Medicare package 
before forwarding to the CMS RO; and 
 
  Inform the potential provider or provider undergoing a CHOW that the Medicare 
application will not be forwarded to CMS until the civil rights documents and 
forms have been completed and returned to the SA.  
 
NOTE:  OCR has Civil Rights Corporate Agreements (Agreements) with certain health 
care corporations.  Providers that belong to those corporations need to submit 
ONLY the signed certification sheets, as specified in the corporations 
Agreements. 
 
Processing OCR Documents - Upon receipt of the OCR documents, the CMS RO 
forwards them to the OCR for processing and clearance.  The role of the SA and CMS is 
limited to obtaining the documents and forwarding them to OCR.  
 
Copies of the current version of the Packet can be downloaded from 
http://www.hhs.gov/ocr/civilrights/resources/providers/medicare_providers/index.html.   
SAs must include this link with their initial certification and CHOW packages.  
 
Regarding Medicaid-only providers, the States themselves are recipients of the Federal 
funds and may be considered to have a direct obligation to assure OCR of their 
compliance by assuring that funds go to providers who are in compliance.  As with 
Medicare, potential providers or providers undergoing a CHOW must be determined to be 
in compliance with civil rights laws by OCR as a condition for approving the providers 
participation in the Medicaid program. 
 
2012 - SA Identifying Eligible Providers and Suppliers 
(Rev. 1, 05-21-04) 
  Initial certifications of providers or suppliers involve steps, including enrollment, to 
survey applying providers/suppliers and confirm their eligibility. These steps are not 
repeated on cyclical recertification if the basic eligibility factors have not changed.  Since 
the requirements in the statute and regulations differ for specific provider/supplier 
categories, the initial identification and screening procedures are unique to each type of 
provider or supplier. 
 
For Medicare purposes, the SA initial certification of compliance occurs before the RO 
makes its official determination that the provider/supplier meets all necessary 
requirements. The SA may contact the RO for advice if some aspect of Medicare 
eligibility is in dispute. Ordinarily, the SA develops as much information on the issue as is 
appropriate, completes the certification, and forwards the documentation to the RO for its 
decision. The SA should use the following criteria: 
 
  If the provider/supplier meets the CoPs, Conditions for Coverage, or in substantial 
compliance with the Requirements for SNFs, and is in full compliance with all 
other requirements, i.e., no deficiencies, send the Certification and Transmittal 
(Form CMS-1539) and all other documents to the RO within 10 calendar days of 
the survey; or  
 
  When the provider/supplier meets the CoPs or Conditions for Coverage, but it fails 
to meet other requirements, i.e., it has deficiencies below the Condition level, 
transmit all documentation to the RO within 45 calendar days of the survey.  A 
provider/supplier found to be deficient with one or more standards, or other 
requirements below the Condition level may participate if it has submitted an 
approved PoC for achieving compliance within a reasonable period of time.  A 
PoC must be submitted within 10 calendar days of the facilitys receipt of the 
official Form CMS-2567.  The entity may be granted additional time if the plan is 
complex.  (See Chapter 7 for SNFs and NFs.) 
 
Provider institutions are often complex health care delivery institutions centered around 
primary short-term hospitals.  Although a totally new hospital may be rare, provider 
complexes frequently re-combine and reform or merge.  This may or may not create new 
certification entities.  In general, if the statute or regulations provide for separate 
certification of related or satellite components, they must be separately certified, e.g., a 
distinct part SNF in a hospital. 
 
In some instances a satellites certification depends upon the primary provider being 
approved to participate, e.g., a hospital-based hospice or an ESRD transplant center.  The 
SA should recognize and act upon organizational combinations, and complete Form CMS-
1539 to reflect a change.  A provider is the party having ultimate responsibility and 
liability for the operational decisions of the institution.  Consequently, the SA should 
know what components are under the control of the providers governing body (as 
opposed to being loosely affiliated), and when the governing bodys control of a 
component has changed. 
 
2016 - Readmission to Medicare or Medicaid Program After Involuntary  Termination - Reasonable Assurance 
(Rev. 1, 05-21-04) 
 
(See also Chapter 7 for SNFs and NFs.) 
 
2016A - Readmission Criteria 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
After involuntary termination of a providers agreement, an institution cannot participate 
in the Medicare or Medicaid program again unless: 
 
The provider submits with its request for readmission sufficient justification to 
indicate that the reasons for termination no longer exist; and 
 
All of the applicable statutory and regulatory requirements are met; or 
 
There is reasonable assurance for Medicare entities or Medicaid ICFs/IID 
(terminated under 1910(b) of the Act by CMS) that the deficiencies that caused 
the termination will not recur. 
 
2016B - Reasonable Assurance Concept 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
A Medicare provider terminated under 42 CFR 489.53 and reinstated under 42 CFR 
489.57 or a Medicaid ICF/IID provider terminated pursuant to 1910(b)(1) of the Act is 
required to operate for a certain period of time without recurrence of the deficiencies 
which were the basis for the termination.  The reasonable assurance concept also applies 
to terminated Medicare suppliers such as ASCs (42 CFR 416.35(e)), FQHCs (42 CFR 
405.2440), RHCs (42 CFR 405.2404(e)), and ESRD facilities (42 CFR 405.2180(c)). 
 
The length of this reasonable assurance period is determined by the RO after an 
evaluation of the provider or suppliers previous compliance history.  Reasonable 
assurance periods are usually 30-120 days, but depending on the circumstances, can be for 
a shorter or longer period of time.  Participation can only resume following that period if 
the provider or supplier has maintained compliance with program requirements. 
 
The RO determines the reasonable assurance period for: 
 
  Medicare suppliers; 
 
  Medicare providers, including a SNF in a dually-participating facility, 
terminated pursuant to 1866(b)(2) of the Act; and 
 
  ICFs/IID terminated by CMS pursuant to 1910(b)(1) of the Act. 
 
In considering the decision to readmit a previously-terminated provider/supplier to the 
Medicare or Medicaid program, the RO takes into account not only certification, but also  the intermediarys statement concerning the institutions financial responsibility and the 
OCRs report on compliance with civil rights requirements. 
NOTE:  There is no statutory or regulatory requirement that States must establish a 
reasonable assurance period for Medicaid-only facilities or a NF in a dually-participating 
facility that has been terminated by the SMA under 1902(i) and 1919(h)(1) of the Act. 
The reasonable assurance decision is an administrative action (not an initial determination) 
and is not subject to the appeals process at 42 CFR Part 498.3(d)(5). 
 
NOTE:  These provisions do not apply where a termination action was the result of a 
sanction imposed by the OIG.  The RO forwards reinstatement requests involving these 
provisions to the OIG for appropriate action.) 
 
To determine the reasonable assurance period, the RO will evaluate the following: 
 
1.   Providers or Suppliers Compliance History 
 
When the provider/supplier previously participated in either Medicare or Medicaid 
(ICF/IID), was compliance maintained historically?   
 
Were PoCs implemented on time?   
 
Does the provider/supplier have a history of making good faith efforts to correct 
deficiencies and to maintain compliance?   
 
Does it have a record of being cited repeatedly for essentially the same problems?  
 
Were previous adverse actions initiated, but not put into effect? 
 
2.   Previous Adverse Action 
 
Has the applicant/institution previously been terminated and readmitted to the Medicare 
program?  If yes: 
 
How long was compliance maintained after being readmitted? 
 
Have all deficiencies been corrected? 
 
Are corrective actions permanent; i.e., is compliance likely to continue? 
 
3.   Other Factors Impacting Continued Compliance 
 
Is the facility located in an area that is underserved by health professionals, meaning that 
staffing deficiencies may continue?   
 
Does the applicants pay scale or the facilitys location deter the hiring and retention of 
staff?  
Does it have inherent problems that are likely to cause recurrence of significant  deficiencies? 
 
Has there been a change in staff or services furnished that might affect continued 
compliance?  
 
The following are examples using these criteria to determine reasonable assurance periods.  
(See Chapter 7 for examples for SNFs/NFs.) 
 
EXAMPLE A: 
 
Green Acres Community Hospital was terminated on November 1, 1996.  The provider 
was cited as not meeting several CoPs.  On December 1, 1996, the hospital board alleged 
to have corrected all deficiencies the SA found. While reviewing the providers 
compliance history, the RO notes that one or more CoPs were cited in previous surveys, 
but the provider usually managed to achieve compliance just before termination.  
 
Reasonable Assurance - The RO establishes 90 days from December 1, 1996, as 
reasonable based on the providers history of not maintaining compliance. 
 
EXAMPLE B: 
 
Fox Chase General Hospital was terminated on December 21, 1996, for its failure to 
maintain required staffing in nursing, dietary, and medical records.  On January 2, 1997, 
the provider alleged that he hired the necessary staff and requested readmission.  Upon 
review, the RO finds that the provider is located in a remote, under-served rural area and 
has been unable to maintain staff since participation began in 1989. 
 
Reasonable Assurance - The RO establishes 90 days from January 2, 1997, as reasonable 
on the grounds that the location of the provider has militated against staff retention, and 
that 3 months of continued compliance would evidence the providers ability to retain 
qualified health professionals. 
 
EXAMPLE C: 
 
The XYZ Home Health Agency was terminated on September 15, 1997.  On the four prior 
surveys the agency had been cited for failure to meet several of the CoPs, but had, until 
the most recent survey, achieved compliance before termination action was completed. On 
October 1, 1997, the agency alleged compliance. 
 
Reasonable Assurance - The RO establishes a 120-day reasonable assurance period 
based on the providers repeated failure to meet the CoPs necessary to ensure the health 
and safety of patients.  
 
EXAMPLE D: 
 
The Visiting Nurses, Inc., was readmitted following a 60-day reasonable assurance period. 
On the next survey, The Visiting Nurses, Inc., is found not to meet one or more CoPs and  is again terminated.  The provider corrects the deficiencies and requests readmission. 
 
Reasonable Assurance - The RO establishes a 120-day waiting period based on prior 
termination and failure to maintain compliance following a 2-month reasonable assurance 
period. 
 
EXAMPLE E 
 
Pleasant Plains ICF/IID was terminated by CMS on January 10, 1996.  The provider was 
terminated for deficiencies that posed a threat to client health or safety.  The provider 
corrected its deficiencies and requested readmission on February 1, 1996.  The SA 
surveyed the facility on February 10, 1996, and determined that the deficiencies that were 
the reason for the termination had been corrected and certified compliance.  The 
documentation was forwarded to the RO on February 21, 1996.  While reviewing all 
available documentation, the RO finds that the provider has a history of serious 
deficiencies.  Moreover, the deficiencies that led to termination have been cited 
repeatedly. 
 
Reasonable Assurance - The RO establishes a 180-day waiting period based on the 
providers history of serious deficiencies and disregard for the health and safety of 
patients. 
 
2016C - Request for Readmission 
(Rev. 1, 05-21-04) 
 
A terminated provider or supplier may reapply for certification at any time.  Upon receipt 
of a request from an involuntarily terminated entity that desires readmission to the 
program, the SA immediately contacts the entity and informs it of the requirements for 
readmission.  If the reasonable assurance time-period was not established at the time of 
termination, the SA contacts the RO and requests that it establish the reasonable assurance 
period so that it may be included in the letter to the facility informing it of the 
requirements for readmission to the program.  (The RO may choose to delay 
establishment of the reasonable assurance period pending the results of the first 
survey.)  Use Exhibit 41 to inform the provider or supplier of the reasonable assurance 
provisions and to transmit the required documents necessary for future participation.  (See 
the applicable initial certification section in Exhibit 63 for the required documents.) 
 
If the institution then indicates that it meets the requirements for participation and returns 
the initial application packet, forward the application packet to the RO via a Form CMS-
1539.  The RO will contact the previous servicing intermediary.  The intermediary, in 
turn, advises the RO whether there are any outstanding financial problems, such as 
overpayments, that need to be resolved before the institution is readmitted.  In addition, 
the RO takes immediate action to obtain title VI clearance. 
 
2016D - Reasonable Assurance Surveys 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
  Upon receipt of the initial application packet from the SA, the RO will provide the SA 
with instructions concerning how to conduct the necessary reasonable assurance surveys. 
 
Two surveys are required for Medicare certification to verify that the reason for 
termination no longer exists, and that the provider/supplier has maintained continued 
compliance.  At least one of these surveys must be a full/standard survey to ensure that all 
CoPs/CfCs are met or the SNF is in substantial compliance.  The RO has the discretion to 
determine whether both surveys will be full/standard surveys, or whether one may be a 
partial survey to document compliance with requirements for which there were previous 
deficiencies.  If the RO decides that one survey will be a partial survey, the RO also 
decides whether the partial survey will be the first or the second survey.   (CMS, at its 
discretion, conducts the survey for a ICF/IID it originally surveyed and terminated 
pursuant to 1910(b)(1) of the Act.) 
 
The reasonable assurance period of time begins on the date of completion of the first 
survey documenting compliance with requirements for which there were prior 
deficiencies.  
 
The SA conducts the first of the reasonable assurance surveys as instructed by the RO and 
submits the results of the survey (this may be submitted on Form CMS-2567) to the RO 
within 10 working days of the survey.  Based on the results of this first survey, the RO 
determines if the reasons for termination no longer exist, or for SNFs, the deficiencies that 
caused their termination are at the level of substantial compliance.  The RO notifies the 
SA and the provider/supplier of its determination.  If the RO determines that the reasons 
for termination no longer exist, or for SNFs that the deficiencies that caused the 
termination are at the level of substantial compliance, the reasonable assurance period 
begins effective with the last day of this first survey.  If not, the provider must reapply. 
 
Once the RO determines that the reasonable assurance period has begun, the SA will 
schedule a second survey to coincide with the end of the reasonable assurance period. 
 
The SA informs the RO of the scheduled survey date.  The SA conducts the survey, 
completes the Survey Report (as applicable), and prepares a statement to accompany Form 
CMS-1539 that includes: 
 
  The finding that the deficiencies which led to termination of the provider 
agreement have (or have not) been corrected; 
 
  The evidence showing that compliance has been maintained, and the reasons for 
concluding that the deficiencies will not recur; and 
 
  A description of any other deficiencies and, if appropriate, an explanation as to 
why the facility is nevertheless in compliance with all CoPs or the SNF is in 
substantial compliance (see 7203.B and 7300.C). 
 
If the RO determines after the second survey that the reasons for termination continues to 
exist and/or determines that the provider/supplier does not meet the CoPs or the SNF is  not in substantial compliance, the provider/supplier must again begin the reasonable 
assurance process to gain reentry into the program(s).  (See 7203.B and 7300.C for the 
exception for SNFs and NFs.) 
 
If an involuntarily terminated provider/supplier attempts to re-enter the Medicare program 
via deemed status accreditation under a CMS-approved Medicare accreditation program, it 
must still satisfy the reasonable assurance requirements at 42 CFR 489.57.  The RO has 
the discretion to deny Medicare reentry based solely on deemed status accreditation 
surveys and may instead require two surveys be performed by the SA if it is not 
reasonably assured the provider/supplier meets the Medicare conditions.  The RO also has 
the discretion to accept an accreditation survey for either the first or second of the 
reasonable assurance surveys.  Generally an AO would not conduct both reasonable 
assurance surveys, but if it is willing to do so and the RO is reasonably assured that the 
provider/supplier meets the Medicare conditions, the RO may permit the AO to conduct 
both reasonable assurance surveys. 
 
In cases involving readmission of an involuntarily terminated provider seeking deemed 
status, the RO will determine the IF (when it is reasonably assured that the reason for the 
termination will not occur), the WHEN (the reinstatement effective date) and the HOW 
(e.g., a survey by the SA) of the providers/suppliers reentry into the Medicare program.  
The RO will make an analysis of the facts in the case and issue a decision because 
receiving deemed status is a separate issue from reinstatement (Reasonable Assurance) 
following involuntary termination by CMS under 42 CFR 489.57. 
 
The regulation at 42 CFR 489.57 does not apply to a providers voluntary termination of 
its agreement under the provisions of the regulation at 42 CFR 489.52.  In a scenario 
similar to the situation described above except that the providers termination from 
Medicare was voluntary, CMS (the RO) would still be responsible for the if, when and 
how of the provider agreement under 42 CFR 489.12.  However, the providers 
accreditation by a recognized accrediting body and subsequent deemed status would mean 
that compliance with the CoP would not be one of the unmet requirements under title 
XVIII of the Act that could be invoked under 42 CFR 489.12(a)(3).  This is pointed out 
because some providers voluntarily withdraw from Medicare in the face of a proposed 
involuntary termination.  A RO could decide to process an involuntary termination in such 
a case.  In the absence of having processed an involuntary termination, the RO could apply 
42 CFR 488.6(c)(2) in concert with 42 CFR 489.12(a)(3) in a case where a provider facing 
involuntary termination voluntarily withdrew from Medicare and subsequently attempted 
to re-enter the program through accreditation under a CMS-approved Medicare 
accreditation program. 
 
The regulation at 42 CFR 489.57 also does not apply to a providers initial application for 
Medicare participation.  Again, as with a voluntary termination, the CMS (RO) is 
responsible for the if, when and how of the provider agreement and a decision to deny the 
provider an agreement must be in accordance with 42 CFR 489.12.  Also, if an accrediting 
organization has determined that the provider is accredited, the provider is deemed to meet 
the Medicare conditions and we would have satisfactory assurance of compliance with the 
conditions under 42 CFR 489.12(a)(3).  However, as with a voluntary termination, we  might look at 42 CFR 488.6(c)(2) in tandem with 42 CFR 489.12(a)(3) in an individual 
case.  This means that we should notify accrediting bodies if and when we deny a provider 
entry into Medicare based on a State survey agency survey.  This includes providers that 
are surveyed by the State but do not respond to a Statement of Deficiencies. 
 
2016E - Effective Date of Provider Agreement After Reasonable 
Assurance 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
If the provider or supplier has maintained compliance throughout the reasonable assurance 
period, it may reenter the program and be issued a new provider agreement or supplier 
approval.  The effective date of the new Medicare agreement and Medicaid FFP is 
calculated based on the date of completion of the second reasonable assurance survey.  
See Section 2008D for details on the calculation of the effective date. 
 
2016F - Readmission of ICF/IID After Termination 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Before the SMA readmits an ICF/IID to the Medicaid program after termination by CMS 
pursuant to 1910(b)(1) of the Act, the RO must determine that the facility has provided 
the SA reasonable assurance that the deficiencies that were the cause for termination will 
not recur.  The RO will determine the reasonable assurance period, and the RO, or the SA, 
at the ROs request, will monitor the facility to determine that it remains in compliance for 
the period of time designated by the RO as the reasonable assurance period.  The SA or 
the RO will monitor the facility by conducting the necessary survey and revisits. 
 
The reasonable assurance period must be satisfied before the SMA issues an agreement to 
that facility and before that facility can qualify for FFP.  Failure to provide reasonable 
assurance is a basis for CMS to continue to disallow FFP for services furnished by that 
facility.  (See 42 CFR Part 442.30 and 431.610(f)(1).) 
 
2016G - Under LSC at Time of Readmission 
(Rev. 1, 05-21-04) 
 
1.   Termination Based on LSC or Health Conditions 
 
Upon readmission, an institution that was terminated for noncompliance with the LSC 
must be surveyed under the edition of the Code in effect under current regulations. 
 
2017 - Readmission Following Voluntary Termination of Program 
Participation  
(Rev. 1, 05-21-04) 
 
If termination action has been initiated but the entity is allowed to terminate Medicare 
participation voluntarily before the action is made effective, the reasonable assurance 
provision will be applied.  If there is not a SA certification of noncompliance at the time a  provider/supplier notifies the RO of voluntary termination, the reasonable assurance 
provision does not apply. 
 
2018 - Reinstatement Following Termination of Swing-Bed - Approval 
(Rev. 1, 05-21-04) 
 
If swing-bed approval has been terminated for any reason, there is a statutory 2-year 
minimum waiting period for reinstatement. Do not apply the reasonable assurance 
concept in these situations.  (See 1883(c) of the Act.) 
  Hospitals 
 
2020 - Hospitals - Definition and Citations 
(Rev. 1, 05-21-04) 
 
A hospital is defined in 1861(e)(1) of the Act.  A hospital is an institution primarily 
engaged in providing, by or under the supervision of physicians, inpatient diagnostic and 
therapeutic services or rehabilitation services.  The remainder of 1861(e) defines a 
hospital eligible for Medicare participation.  Section 1861(f) defines Medicare eligible 
psychiatric hospitals.  42 CFR 482 sets forth the CoPs for hospitals, including psychiatric 
hospitals.  The interpretive guidelines for hospitals appear in Appendix A and 
Appendix AA. 
 
2021  Non-deemed Hospitals 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
2021A  Recertification of Non- deemed Hospitals 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Hospitals that are certified for Medicare participation based on a SA survey should be 
recertified on a schedule consistent with the survey guidelines for non-deemed hospitals 
issued by CMS each fiscal year.  A recertification packet for each hospital is to be sent to 
the RO by the SA.  Exhibit 63 has a complete list of documents to be completed and 
included in the recertification packet.  The Certification & Transmittal Form, CMS-1539 
(C&T), which is part of the recertification packet, should indicate in the remarks section 
that the C&T is transmitting a non-deemed hospital recertification.  If the hospital has 
undergone a change of ownership with acceptance of assignment of the Medicare provider 
agreement by the new owner since the last recertification survey, also indicate if a Change 
of Ownership (CHOW) package was forwarded to the hospital by the SA. 
 
In addition, the SA also updates Exhibit 286, the Hospital/CAH Medicare Database 
Worksheet, with any new information regarding the hospital.  It is not permissible to 
forward the Hospital/CAH Medicare Database Worksheet to the hospital for completion. 
The SAs are not expected to conduct an onsite visit of the hospital solely to obtain 
information for the worksheet.  However, the SAs may be able to use State licensure data 
to update the worksheet.  The updated Hospital/CAH Medicare Database Worksheet 
should be forwarded with the recertification packet to the RO.  The ASPEN system must 
also be updated to reflect any changes to the information on the Hospital/CAH Medicare 
Database Worksheet.  This policy applies to ALL non-deemed hospitals. 
 
2022 - Deemed Status: Hospitals Accredited by an Accrediting 
Organization with a CMS-approved Medicare Hospital or Medicare 
Psychiatric Hospital Accreditation Program 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
  2022A - Notice that a Participating Hospital Has Been Accredited and 
Recommended for Deemed Status 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
A hospital accredited and recommended for deemed status by a national accreditation 
organization with a CMS-approved Medicare hospital accreditation program may be 
deemed to meet all CoPs for hospitals (except the SNF Requirements for swing-bed 
designation and any higher-than-national standards approved by the Secretary for a State 
under 1863 of the Act).  Additionally, a psychiatric hospital accredited and 
recommended for deemed status by a national accreditation organization with a CMS-
approved Medicare psychiatric hospital accreditation program may be deemed to meet all 
CoPs for psychiatric hospitals.  
 
When notified that a participating hospital or psychiatric hospital has been accredited and 
recommended for deemed status, the RO verifies the accreditation and recommendation 
for deemed status and notifies the SA.  The SA executes Form CMS-1539 to report the 
accreditation and recommendation for deemed status. 
 
2022B - Recertification 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Hospitals or psychiatric hospitals that receive their Medicare certification via deemed 
status based on accreditation by a CMS-approved Accreditation Organization (AO) should 
be recertified by the State Survey Agency (SA) on a schedule consistent with the 
accreditation interval of the AO.  Upon receipt of a notice from the AO indicating that it 
has renewed a hospitals accreditation and is recommending continued deemed status, a 
recertification kit should be created in the Automated Survey Processing Environment 
(ASPEN) or recertification packet for each deemed hospital or psychiatric hospital is to be 
sent to the RO by the SA.  Exhibit 63 has a complete list of documents to be completed 
and included in the recertification packet.  The Certification & Transmittal Form, CMS-
1539 (C&T), which is part of the recertification packet, should indicate in the remarks 
section that the C&T is transmitting an accredited hospital recertification. 
 
In addition, the SA also updates the Hospital/CAH Medicare Database Worksheet, Exhibit 
286, with any new information regarding the hospital.  It is not permissible to forward the 
Hospital/CAH Medicare Database Worksheet to the hospital for completion. The SAs are 
not expected to conduct an onsite visit of a deemed hospital solely to obtain information 
for the worksheet.  However, the SAs may be able to use State licensure data to update the 
worksheet.  The updated Hospital/CAH Medicare Database Worksheet must be entered 
into ASPEN and be included in the recertification kit forwarded to the RO; the 
recertification kit will not upload to the national data base unless a Hospital/CAH 
Medicare Database Worksheet has been completed. 
 
2022C - Notification of Withdrawal or Loss of Accreditation 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
See Section 2005B.   
2024 - Hospital Merger/Multiple Campus Criteria 
(Rev. 1, 05-21-04) 
 
When two or more hospitals merge, the SA ascertains whether to continue to certify the 
hospitals separately or to certify them as a single hospital (i.e., hospital with a main 
campus and an additional location).  Also, when a hospital establishes an additional 
hospital facility, geographically separate but in the same metropolitan area, the SA 
determines whether the additional hospital facility will be certified as a separate hospital 
or whether it can be considered a single hospital.  A hospital may establish an additional 
hospital facility so organizationally or geographically separate as to make it impossible to 
operate as a multi-campus hospital. 
 
Each location of a single hospital must meet the applicable CoPs.  A certification of non-
compliance at the CoP level at any of the hospital locations affects the certification of the 
hospital as a whole.  Consequently, when noncompliance at the CoP level is found, the 
hospital will either be denied participation or terminated from participation in the 
Medicare/Medicaid program.  When a hospital is to be terminated, the SA follows the 
termination procedures contained in 3010 and 3012. 
In addition, all locations of a single hospital must comply with applicable State licensure 
laws.  When it is determined that any of the hospital locations does not comply with State 
licensure laws, the hospital as a whole will either be denied participation or terminated 
from participation in the Medicare/Medicaid program. 
 
Where two or more previously separate hospitals merge, all locations of the surviving 
hospital must meet the criteria found in 2004.  In addition, all non-hospital providers of 
service under Medicare that state they are part of a single hospital must meet the criteria 
for provider based designation in 2004 in order to be treated as a single hospital for 
payment purposes. 
 
2026 - Certification of Parts of Institutions as Hospitals 
(Rev. 1, 05-21-04) 
 
 
2026A - Hospitals (Other Than Psychiatric Hospitals) 
(Rev. 1, 05-21-04) 
 
The SA evaluates each general hospital as a whole for compliance with the CoPs and 
certify it as a single provider institution including all components: 
 
  Under the legal control of the hospital governing body and part of the same 
corporation or governmental administrative entity; and 
 
  Subject to the direction of the hospital administrator and medical staff 
organization. 
 
The SA evaluates and certifies the whole hospital even when the components are  separately housed. 
 
It is not permissible to certify only part of a general hospital.  However, the following are 
not considered parts of the hospital and are not to be included in the evaluation of the 
hospitals compliance: 
 
  Components appropriately certified as other kinds of providers or suppliers. i.e., a 
distinct part SNF and/or distinct part NF, HHA, RHC or hospice; and 
 
  Excluded residential, custodial, and non-service units not meeting the definitions 
in 1861(e)(1) or (j)(1) of the Act. 
 
2026B - Excluded Non-Service Units May be Appropriate 
(Rev. 1, 05-21-04) 
 
The hospital ordinarily requests exclusion of a unit by a letter to the RO through the fiscal 
intermediary.  The RO may then ask the SA to certify information it needs to make the 
exclusion. Otherwise, the SA excludes from any regular certification those portions of a 
hospital that are separately identifiable units that do not meet the 1861(e)(1) or (j)(1) 
definitions. 
 
2030 - Temporary Waivers Applicable to Rural Hospitals 
(Rev. 1, 05-21-04) 
 
If a hospital is found to be out of compliance with the 24-hour registered nurse (RN) 
requirement, a temporary waiver may be granted by the RO.  This waiver, however, may 
be approved only to the extent that it would not jeopardize or adversely affect the health 
and safety of patients.  The waiver may be issued for any one-year period or less under 
certain circumstances, and may be withdrawn earlier if this action is necessary to protect 
the health and safety of patients.  The hospital must meet all CoPs except for the waived 
requirement. 
 
In determining whether a hospital qualifies for a waiver, the SA verifies that these 
additional criteria are met: 
 
  The hospital is located in a rural region.  The Census Bureau in the most recent 
census defines Rural as all areas not delineated as an urbanized areas.  (Use the 
material in Appendix G, Standard II A, and Tabs A-C of Appendix G, to ascertain 
whether the area is rural or urbanized); 
 
  The hospital has 50 or fewer beds.  Exclude from the bed-count newborn and 
intensive care beds; 
 
  The character and seriousness of the deficiencies do not adversely affect the health 
and safety of patients; 
 
  The hospital has made and continues to make a good-faith effort to comply with  personnel requirements consistent with the waiver.  Record information 
concerning the hospitals effort to employ additional RNs.  Document the 
recruitment efforts of the hospital and whether the wage level offered is consistent 
with other hospitals in the area.  Hospitals that pay below the wage level for the 
area might not be able to attract new personnel; therefore, the RO might determine 
that they are not making a good-faith effort to attract new nurses; 
 
  The hospitals failure to comply with the 24-hour nursing requirement is 
attributable to a temporary shortage of qualified nursing personnel in the area in 
which the hospital is located.  Obtain and include any information substantiating 
the prediction that the shortage is temporary, e.g., names of personnel scheduled to 
complete qualifying training or scheduled to be engaged and anticipated dates of 
arrival on duty; 
 
  An RN is present on the premises to furnish or supervise nursing services during at 
least the daytime shift 7 days a week; 
 
  On all tours of duty not covered by an RN, a licensed practical (vocational) nurse 
(LPN) is in charge. 
 
The SA includes in the certification package documentation of the above requirements for 
waiver and the most recent 2-week duty roster for RNs and LPNs. 
 
2034 - Time Limit on Temporary Waiver 
(Rev. 1, 05-21-04) 
 
A temporary waiver of the hospital 24-hour RN coverage requirement may not exceed a 
12-month period and may not be renewed.  A shorter period may be recommended.  The 
RO notifies the hospital of: 
 
  The duration of the waiver; 
 
  A list of deficiencies; and 
 
  A statement indicating that the waiver may be removed prior to its stated 
expiration date if the hospital fails to maintain its effort to correct its nursing 
deficiencies. 
 
Regardless of the approved duration of the waiver, it may be withdrawn at any time 
patient health and safety are adversely affected.  Therefore, the SA should plan frequent 
revisits, make telephone contacts, and request nurse staffing duty rosters to monitor the 
hospitals progress and to determine that patient health and safety are not jeopardized.  
The frequency of SA monitoring efforts depends on the hospitals efforts to make 
corrections, the number and types of patients served, functional arrangement and design of 
the patient care facility, and the number and qualifications of the RNs and auxiliary 
nursing personnel. 
  If the SA finds that continuation of the waiver is not appropriate, it documents the case for 
termination of the provider agreement.  Conversely, if it finds that the hospital has 
corrected its nursing deficiency, it certifies the hospital without reference to the prior 
waiver. 
 
2036 - Definition, Authority and Requirements for Hospital Providers of 
Extended Care Services (Swing-Beds) 
(Rev. 1, 05-21-04) 
 
Swing-bed is a reimbursement term that means the care and reimbursement for the care 
of a patient in a small rural hospital or CAH swings from acute care to post hospital 
skilled nursing care (SNF).   A swing-bed hospital means a hospital or CAH participating  
in Medicare that has an approval from CMS to provide post hospital SNF care and meets 
the requirements specified in 482.66 for a hospital or 485.645 for a CAH. 
 
Certification to provide swing-beds is an approval separate from the certification to 
operate as a hospital or CAH.  When a survey of swing-beds is completed, any 
deficiencies and Plans of Correction (PoC) must be documented on a separate Form 
CMS-2567.  If the swing-beds are voluntary terminated or terminated by CMS, that action 
does not affect the continuing operation of the provider as a hospital or CAH.  It 
terminates the approval to operate and receive reimbursement for the swing-beds. 
 
The swing-beds in a hospital or CAH do not have to be separated from the acute patients 
although the facility may choose to do so. The patients do not have to move to a different 
location in the facility when changing from acute care status to swing-bed status unless the 
facility requires it. 
 
There is no length of stay restriction for a swing-bed patient whether they are in a hospital 
or a CAH.  There is no required discharge to a nursing home and no transfer agreement. 
Patients may be discharged to a nursing home as part of discharge planning, but it is not 
required.  
 
A medical order in the chart by the physician is required to change status from acute care 
to swing-bed because the patient is being discharge from acute care status and admitted to 
swing-bed status.  This is necessary for reimbursement purposes because the billing and 
reimbursement change or swing.  Accordingly, the facility is given a subprovider 
number for billing swing-bed services. 
 
For Medicare patients, a 3-day qualifying stay in any hospital or CAH is required to prior 
to admission to a swing-bed and the admission must be for treatment of the same 
condition.  This 3-day qualifying stay only applies to a Medicare patient. 
 
Section 1883 of the Act authorizes payment under Medicare for post-hospital SNF 
services provided by any hospital that meets the following requirements at  
42 CFR 482.66.  These requirements include the following. 
 
  The hospital has a Medicare provider agreement;   
  The facility has fewer than 100 hospital beds, excluding beds for newborns and 
beds in intensive care type inpatient units; 
 
  The hospital is located in a rural area.  This includes all areas not delineated as 
urbanized areas by the Census Bureau, based on the most recent census; 
 
  The hospital does not have in effect a 24-hour nursing waiver granted under 
42 CFR 488.54(c); 
 
  The hospital has not had a swing-bed approval terminated within the two years 
previous to application; 
 
  The hospital meets the Swing-bed CoPs (see 42 CFR 482.66) on Resident Rights; 
Admission, Transfer, and Discharge Rights; Resident Behavior and Facility 
Practices; Patient Activities; Social Services; Discharge Planning; Specialized 
Rehabilitative Services; and Dental Services. 
 
NOTE:  The 30-day patient transfer notice requirement at 42 CFR Part 483.12(a)(5) does 
not apply to swing-bed hospitals. 
 
2037 - Requirements Assessed Prior to Survey for Swing-Bed Approval 
(Rev. 1, 05-21-04) 
 
 
2037A - Request from a Medicare Participating Hospital to Add Swing-
Bed Approval 
(Rev. 1, 05-21-04) 
 
The request can be initiated on the providers letterhead stationery and sent to the SA.  
Acknowledgement and request for further information can be sent from the SA to the 
provider in a letter, see Exhibit 81, Letter Transmitting Materials to a Hospital 
Requesting Swing-bed Approval. 
 
2037B - Screening 
(Rev. 1, 05-21-04) 
 
Prior to scheduling a survey, the SA reviews the provider file as well as any other 
information maintained on the hospital to ascertain whether the six basic requirements are 
met.  If these requirements are met and the hospital has begun to provide swing-bed 
services, the SA schedules a survey.  No hospital may receive initial swing-bed approval 
without an onsite survey of the actual provision of such services.  The SA may send a 
letter to the provider notifying them of the required documents for a future survey, see 
Exhibit 82, Notification to a Hospital Regarding an Initial Survey for Swing-bed 
Approval.  This notice acknowledges that a survey is required and the expectation for 
certain information that will be needed, but it does not disclose the date of the survey. 
  2037C - Provider Agreement 
(Rev. 1, 05-21-04) 
 
Prior to survey the SA verifies that the hospital has a valid Medicare provider agreement. 
 
2037D - Calculation of Bed Count 
(Rev. 1, 05-21-04) 
 
Exclude from the bed count newborn and intensive care beds.  
 
A hospital licensed for more than 100 beds may be eligible for swing-bed approval if it 
utilizes and staffs for fewer than 100 beds.  The SA forwards to the RO documentation 
that the hospital is operating within the bed category.  Include in the packet floor plans, 
bed assignments by room number, staffing schedules, and census information for the 
previous 12 months.  The SA obtains written assurance from appropriate hospital officials 
that the hospital will not operate with a greater number of inpatient hospital beds than 
permitted by the category for which approval is requested. 
 
2037E - Rural Area 
(Rev. 1, 05-21-04) 
 
The SA includes as eligible those facilities that are not located in an urbanized area 
based on the most recent census of the Census Bureau.  Before concluding that a hospital 
is ineligible on the basis of location, the SA telephones the Census Bureau RO for 
verification. 
 
2037F - Certificate Of Need (CON) Approval 
(Rev. 1, 05-21-04) 
 
States that have a  CON requirement for the initiation or expansion of long-term care 
services may require a CON for a limited number of beds for LTC use.  There is no 
federal requirement for a CON but CMS will not intervene if there is a state requirement. 
 
2038 - Survey Procedures for Swing-Bed Approval 
(Rev. 1, 05-21-04) 
 
The SA surveys any hospital that meets the six items listed in 2036 and that has begun to 
provide post-hospital SNF and NF care services.  The SA may choose to use the optional 
Swing-Bed Survey Report that can be found with the Appendix T to record survey 
findings.  
 
The survey for swing-bed approval may be conducted at the same time as a survey of the 
hospital CoP at 42 CFR Part 482, although the findings must be documented on a separate 
Form CMS-2567. 
 
2039 - Post-Survey Procedures for Swing-Bed Hospitals  (Rev. 1, 05-21-04) 
 
To receive swing-bed approval, a hospital must be found in compliance with the 
provisions of 42 CFR Part 482.66 and the specific skilled nursing requirements in  
42 CFR 483 that apply to swing-bed hospitals, see Appendix T.  If a plan of correction is 
required following the survey, send a copy of Exhibit 162, Request for a Plan of 
Correction Following an Initial Survey for Swing-bed Approval in a Hospital to the 
provider. 
 
Effective dates for all swing-bed approvals are based on the provisions at 42 CFR 489.13 
that state the agreements will be effective on the date the onsite survey is completed if all 
Federal requirements are met on the date of the survey.  If the provider fails to meet any of 
the requirements, the approval will be effective on the earlier of the following dates: 
 
  The date on which the hospital meets all requirements, or 
 
  The date the hospital submits a correction plan acceptable to CMS. 
 
2040 - RO Approval Procedures for Swing-Bed Approval 
(Rev. 1, 05-21-04) 
 
The RO prepares a formal determination and notifies the hospital of its approval or denial.  
For approvals, see Exhibit 83,Approval Notification for Swing-beds in a Hospital or 
denials, see Exhibit 83B, Denial for Swing-bed Approval in a Hospital.  
 
If the provider is found to be in non-compliance after they have started to provide swing-
bed services, a termination of the approval can be accomplished through a termination 
letter, see Exhibit 163, Termination Letter for Hospital Swing-Bed Services.  Failure to 
satisfy requirements for swing-bed approval does not affect Medicare approval as a 
provider of hospital services, but it does withdraw the approval to provide SNF level 
services at the hospital. 
 
2042 - Psychiatric Hospitals 
(Rev. 1, 05-21-04) 
 
The statutory requirements for psychiatric hospitals are found in 1861(f) of the Social 
Security Act (the Act.)  The regulatory requirements are found at 42 CFR 482.60  
42 CFR 482.62.  The term psychiatric hospital means an institution which: 
 
  Is primarily engaged in providing, by or under the supervision of a Doctor of 
Medicine or Osteopathy, psychiatric services for the diagnosis and treatment of 
mentally ill persons; 
 
  Satisfies the requirements of 1861(e)(3) through (e)(9) of the Act (general 
hospital requirements); 
 
  Maintains clinical and other records on all patients as the Secretary finds necessary  to determine the degree and intensity of the treatment provided to individuals 
entitled to hospital insurance benefits under Part A; and  
 
  Meets such staffing requirements as the Secretary finds necessary for the 
institution to carry out an active program of treatment for individuals receiving 
services in the institution. 
 
In the case of an institution that satisfies the first two criteria and contains a distinct part 
that also satisfies the last two criteria, the distinct part is considered to be a psychiatric 
hospital. 
 
There are some psychiatric hospitals that are designated as forensic hospitals.  These 
hospitals focus on serving individuals who are in the custody of penal authorities.  As a 
general rule, institutions that house only prisoners are excluded from Medicare payment.  
However, in accordance with 42 CFR 411.4(b) payment may be made for services 
furnished to individuals who are in the custody of penal authorities if (1) State or local law 
requires such individuals to repay the cost of the medical services they receive while in 
custody and (2) the State or local government entity enforces the requirement by billing all 
individuals who are prisoners whether or not they are insured by Medicare on any other 
insurance program.  The pursuit of repayment from the prisoners for Medical services 
must be done with the same vigor as would be done for the collection of any other debts 
owed the state.  The determination of payment eligibility in these cases is made by the FI 
and CMS financial personnel. 
 
Regardless of whether a state meets the payment requirements for prisoners housed in 
these hospitals, the hospital must apply the CoP, including the restraint and seclusion 
rules, to all patients including the prisoners.  If a hospital wants to apply different health 
and safety rules to prisoners, it may want to consider establishing a distinct part. 
 
Medicaid rules for institutionalized individuals are found at 42 CFR 435.1008  435.1009.  
If there is an issue concerning a Medicaid prisoner, contact the RO account representative 
for the particular state for resolution. 
 
2044 - Psychiatric Hospitals and Deemed Status 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Psychiatric hospitals have a Medicare accreditation option available to them.  Prior to this 
being the case, however, CMS permitted a psychiatric hospital to have deemed status with 
respect to all hospital conditions (identified as A tags in ASPEN) except the special 
psychiatric CoPs at 42 CFR 482.60-62 (identified as B tags in ASPEN).  Under this 
arrangement, the AO was responsible for assessing the psychiatric hospitals compliance 
with all other hospital CoPs, i.e., those provisions with A tags, and either the SA or CMS 
contract surveyors assessed compliance with the special psychiatric CoPs, i.e., the B tags.  
Currently almost all deemed status psychiatric hospitals are accredited under the approved 
Medicare psychiatric hospital accreditation program, and their AO is responsible for 
assessing compliance under both the A and B tags.   
  Any psychiatric hospital seeking initial participation in Medicare through deemed status 
must be accredited under a CMS-approved Medicare psychiatric hospital accreditation 
program.  This also is the case for any non-accredited participating psychiatric hospital 
seeking to switch to deemed status.  CMS no longer permits a psychiatric hospital to seek 
participation through deemed status for the A tags only.  However, there are a small 
number of participating psychiatric hospitals that were deemed to meet the requirements 
for the A tags only prior to CMS approving a psychiatric hospital Medicare accreditation 
program.  CMS considers these hospitals to have grandfathered deemed status for the A 
tags only, and SAs or CMS contract surveyors remain responsible for B tag surveys in 
these facilities. 
 
If a psychiatric hospital currently has deemed status for the A tags through accreditation 
by an AO which has a CMS-approved Medicare hospital accreditation program but does 
not have a CMS-approved Medicare psychiatric hospital accreditation program, and the 
psychiatric hospital wishes to be deemed for the special psychiatric hospital CoPs, it must 
seek accreditation from an AO with a CMS-approved Medicare psychiatric hospital 
accreditation program.   In this instance, the psychiatric hospital may not choose to 
continue its current Medicare hospital accreditation with one AO in addition to obtaining 
its new Medicare psychiatric hospital accreditation with another AO; it must withdraw 
from its current Medicare hospital accreditation program and seek or maintain 
accreditation under a CMS-approved Medicare psychiatric hospital accreditation program 
only.  It is not permissible for the psychiatric hospital to both be accredited by one AO 
under its hospital program and by another AO for the special psychiatric CoPs only. 
 
When the SA is responsible for surveying the special psychiatric CoPs of an otherwise 
deemed psychiatric hospital, the SA completes the Medicare/Medicaid Psychiatric 
Hospital Survey Data, Form CMS-724, and all other relevant survey documents (Form 
CMS-2567, etc.) for the survey. 
 
2048 - Distinct Part Psychiatric Hospital 
(Rev. 1, 05-21-04) 
 
2048A - General 
(Rev. 1, 05-21-04) 
 
A psychiatric hospital may elect to participate in its entirety, or it may designate a distinct 
part and apply for Medicare participation of that portion only (see 1886(d)). 
 
The distinct part provisions of the law are designed to permit the participation of those 
identifiable sections of psychiatric hospitals that are adequately staffed, supervised, and 
equipped to provide active treatment on a continuing basis. The participating distinct part 
must meet the hospital CoPs and the two special CoPs and have appropriate treatment 
services available.  Patients in the distinct part must be provided treatment that may 
reasonably be expected to improve their condition. 
 
The provisions for certification of distinct parts of psychiatric hospitals apply only where 
the entire institution is primarily for the treatment of mental illness. Thus, a psychiatric  wing or building of a general hospital or of a large medical center or complex may not be 
certified as a distinct part psychiatric hospital.  Such facilities are included in the 
certification of the institution of which they are an integral part. 
 
2048B - Physical Identification 
(Rev. 1, 05-21-04) 
 
To qualify for participation as a distinct part psychiatric hospital, the distinct part must be 
physically distinguishable from the larger institution or institutional complex; that is, a 
group of beds specifically for patients who need active treatment.  The section(s) or unit(s) 
to be included in the distinct part certification must be clearly defined.  An institution or 
institutional complex can only be certified with one distinct part.  Multiple certifications 
within the institution or institutional complex are strictly prohibited.  The distinct part can 
be a wing, separate building, a floor, a hallway, or one side of a corridor.  The beds in the 
certified distinct part area must be physically separate from (that is, not commingled with) 
the beds of the institution or institutional complex in which it is located.  However, the 
distinct part need not be confined to a single location within the institution or institutional 
complexs physical plant.  It may, for example, consist of several floors or wards in a 
single building or floors or wards that are located throughout several different buildings 
within the institutional complex.  Where an institution or institutional complex owns and 
operates a distinct part, that distinct part is a single distinct part even if it is operated at 
various locations throughout the institution or institutional complex.  The aggregate of the 
locations represents a single distinct part subprovider, not multiple subproviders, and must 
be assigned a single provider number. 
 
Specialized services such as physical therapy and occupational therapy services may be 
included in the distinct part certification.  If any specialized services are included in the 
distinct part, the SA surveys the service and identifies them on Form CMS-1539. 
 
2048C - Documentation of Findings 
(Rev. 1, 05-21-04) 
 
In the documentation on the survey report, the SA includes its observations about the 
distinct part and an assessment of the overall ability of the hospital to provide the services 
required.  As appropriate, the SA must provide information about the entire hospitals 
staffing pattern, such as the number, kind, and location of patient care personnel, including 
physicians, nursing personnel in all categories, social workers, and occupational and other 
therapists. 
 
The nonparticipating portion of an institution is required to meet the CoPs only insofar as 
it affects the health and safety of patients in the distinct part or provides facilities or 
services used by such patients.  In certifying the distinct part, the SA considers the impact 
of nonparticipating sections of the institution to ascertain whether there are any hazardous 
conditions which might endanger patients in the distinct part; for example, the lack of 
adequate fire or sanitation safeguards, particularly where the distinct part is attached to the 
rest of the institution. 
  It is rare that a distinct part of a hospital is completely self-contained.  Therefore, the SA 
evaluates services, facilities, and activities of the overall institution that are provided or 
made available to patients throughout the institution. 
 
Inpatients of the distinct part may receive specialized services such as physical therapy or 
occupational therapy in a portion of the hospital not included in the distinct part.  Services 
and facilities that may be shared vary with the type and size of the institution and the size 
of the distinct part.  However, in most instances, the distinct part shares with the rest of the 
institution such central support services as dietary, housekeeping, maintenance, 
administration and supervision, and some medical and therapeutic services. 
 
The primary consideration in evaluation of shared services is whether the sharing can be 
done without sacrifice to the quality of care given the patients in the distinct part and 
without endangering their health and safety. 
 
Where personnel assignments are shared, the SA should show the extent of sharing.  The 
SA verifies copies of staffing patterns and assignments furnished by the institution 
through personal observation, interviews with various personnel, examination of job 
descriptions and personnel records, and inspection of patient clinical records.  The SA 
reviews medical records for an indication of the extent to which patients of the distinct 
part receive the services of skilled personnel. 
 
In general, the distinct part, either by itself or in conjunction with the overall institution of 
which it is a part, must be able to demonstrate the capacity to provide the services, 
facilities, and supervision required by the CoPs to patients of the distinct part. 
 
2050 - Medical-Surgical Unit of Psychiatric Hospitals 
(Rev. 1, 05-21-04) 
 
A medical-surgical unit of a psychiatric hospital may qualify for participation as a general 
hospital independent of the institution as a whole, regardless of whether the remainder of 
the institution is participating.  The unit is regarded as a separate institution for this 
purpose since the law does not provide for the participation of a distinct part general 
hospital.  It must be a separate, functioning entity that is a distinct and identifiable unit 
within the institutional complex and be in compliance with all the CoPs for hospitals.  
Although a medical-surgical unit may find it necessary to share some services with the 
nonparticipating part of the institution, the location of shared services in relation to the 
medical-surgical unit must clearly show that the latter meets the CoPs. 
 
2052 - Nonparticipating Emergency Hospitals 
(Rev. 1, 05-21-04) 
 
 
2052A - Emergency Hospital Services 
(Rev. 1, 05-21-04) 
 
Any nonparticipating hospital meeting the definition of an emergency hospital for  Medicare purposes may claim payment for emergency inpatient and outpatient diagnostic 
services furnished to Medicare patients.  There are six statutory requirements that a 
hospital must meet to qualify as an emergency hospital (1861(e)(1), (2), (3), (4), (5), and 
(7)). The hospital must: 
 
  Be primarily engaged in providing, by or under the supervision of physicians, to 
inpatients, diagnostic and therapeutic services or rehabilitation services; 
 
  Maintain clinical records on all patients; 
 
  Have bylaws in effect with respect to its staff of physicians; 
 
  Have a requirement that every patient must be under the care of a physician; 
 
  Provide 24-hour nursing service rendered or supervised by a registered 
professional nurse and have a licensed, practical, or registered professional nurse 
on duty at all times; and, 
 
  Be licensed or meet standards for licensing pursuant to State and local law. 
 
2052B - Preparation of Initial Certification 
(Rev. 1, 05-21-04) 
 
  For the initial certification, the SA obtains a completed Hospital Request to 
Establish Eligibility, Form CMS-1514.  The SA annotates at the top; Emergency 
Hospital Services Only. When possible, the SA evaluates the capability of an 
institution to meet the statutory requirements from information contained in State 
licensure files and other available State records or through previous contacts with 
the hospital. 
 
  The SA prepares a Form CMS-1539, completing items 3, 4, 6, 7, 9, 12, 13, and 16 
- 18. 
 
2052C - Recertification and Follow-Up 
(Rev. 1, 05-21-04) 
 
The SA maintains an emergency hospital listing on a continuous basis and annually 
recheck it to ensure that the certifications are still correct.  If a hospital no longer meets the 
definition of an emergency hospital, the SA prepares a new Form CMS-1539. 
 
2053 - Medicaid-Only Hospitals 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Many hospitals choose to participate in both the Medicare and Medicaid programs.  
However, a hospital may choose to only participate in Medicaid.  Medicaid regulations at 
42 CFR 440.10 and 42 CFR 440.140(a) require a hospital or psychiatric hospital (also 
referred to in Medicaid as an institution for mental disease, which is defined at 42 CFR  435.1010) participating in Medicaid to meet the requirements for participation in 
Medicare in order to receive Medicaid payment.  These regulations do not require a 
hospital or psychiatric hospital to enroll in the Medicare program in order to demonstrate 
compliance with Medicare participation requirements.  The provider agreement rules at 42 
CFR 489.10 establish the basic Medicare participation requirements for providers, 
including requirements for hospital participation.  These requirements include, but are not 
limited to, complying with the following:  applicable hospital Conditions of Participation 
(CoPs) at 42 CFR Part 482; specified Office of Civil Rights requirements; and the 
advanced directive requirements at 42 CFR 489.100 and 42 CFR 489.102. 
 
2053A- Initial Certification of Medicaid-Only Hospitals  
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Hospitals seeking initial certification to participate in the Medicaid program only must 
contact the State Agency (SA), in accordance with 1902(a)(9)(A) and 1902(a)(33) of 
the Act, to initiate the certification process.   Requirements for this process are established 
in the Medicaid State Plans required written agreement (or formal written intra-agency 
arrangement) between the State Medicaid Agency (SMA) and the SA (See 42 CFR 
431.610(f). 
 
The SMA must approve the hospitals request for enrollment into the Medicaid program 
prior to the initiation of the certification process by the SA.  
 
2053B - Certification Surveys of Medicaid-Only Hospitals 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
Following verification by the SMA that the enrollment application process has been 
initiated by the hospital, the SA must determine if the hospital seeking Medicaid-only 
certification demonstrates compliance with requirements for Medicare participation, 
including all applicable CoPs, through the completion of an on-site survey.  Hospitals 
have the option of establishing compliance with applicable CoPs through accreditation 
under 42 CFR 488.6(b) by a nationally recognized Accreditation Organization (AO) with 
a CMS-approved Medicare hospital or psychiatric hospital program.  Hospitals choosing 
this option must provide the SA with a letter issued by the AO confirming its accreditation 
under a CMS-approved Medicare accreditation program and recommending deemed status 
as a Medicaid-only hospital.  (As with Medicare-participating hospitals, it is possible that 
a hospital might be accredited, but not have deemed status.  The AO letter must indicate 
the hospital is recommended for deemed status.)  However, regardless of whether the 
survey is conducted by the SA or a CMS-approved AO, the SA must issue a determination 
to the SMA as to whether the hospital has met all Medicare participation requirements for 
Medicaid-only hospital participation. 
 
Upon receipt of the SAs determination, the SMA issues an effective date for the 
hospitals participation in the State Medicaid program. The SA then compiles and 
forwards a Medicaid-only certification packet to the RO.  This packet consists of the 
hospitals request for an applicable Medicaid-only hospital or psychiatric hospital CMS 
Certification Number (CCN), the SAs certification of compliance with Medicare CoPs,  and the SMA-issued State Medicaid program effective date.   After review of all 
documentation, the RO issues the appropriate Medicaid-only hospital CCN.    
 
2053C - Change in Certification 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
If the hospital decides to seek participation in Medicare as well as Medicaid, see Section 
2777D3.  
 
2053D - Termination 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The SMA must terminate the hospitals Medicaid agreement when the SA determines that 
the hospital does not meet the applicable requirements.  See Section 3005C-3.  
 
2053E - Complaint Investigation 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
All allegations of non-compliance with Federal or State requirements in Medicaid-only 
hospitals must be referred to the SA. 
 
Under 42 CFR 431.610, the SA in collaboration with the SMA must determine the 
policies and procedures for the intake, triage and investigation of all allegations of non-
compliance in both deemed and non-deemed Medicaid-only hospitals.  The SA is solely 
responsible for reporting complaint investigation findings  to the SMA, including a 
determination  whether a Medicaid-only hospital meets Medicare CoPs and other federal 
requirements in accordance with 1902(a)(33)(B) of the Act. 
 
2054 - Religious Nonmedical Health Care Institutions (RNHCIs) 
(Rev. 1, 05-21-04) 
 
Section 4454 of the Balanced Budget Act of 1997 (BBA97, Public Law No. 105-33, 
enacted August 5, 1997) deletes statutory references to Christian Science Sanatoria and 
amended the following sections of the Act: 1821, 1861(e), (y) and (ss), 1869, and 1878 
(Medicare provisions); 1902(a) and 1908(e)(1) (Medicaid provisions); and  
1122 (h) and 1162 (conforming provisions).  Additionally, 4454 provides for coverage of 
inpatient services furnished in qualified RNHCIs under Medicare and as a State Plan 
option under Medicaid.  The new amendments make it possible for RNHCIs meeting the 
defining criteria in 4454 of BBA97 or 1861(ss)(1), to participate in the Medicare 
and/or Medicaid program.  The RNHCI provider is responsible for meeting both 
Conditions of Coverage and Conditions of Participation to qualify as a Medicare provider 
and that portion of the Conditions of Coverage that define an RNHCI and the Conditions 
of Participation to qualify as a Medicaid provider. 
 
 
  2054.1 - Certification of Religious Nonmedical Healthcare Institutions 
(RNHCIs) 
(Rev. 1, 05-21-04) 
 
The Boston Regional Office has the primary responsibility for the approval and 
certification process to ensure and verify that the RNHCI conforms to specific Conditions 
of Coverage and all of the Conditions of Participation.  An RNHCI is a provider that 
meets the definition as described in 1861(ss)(1) of the Act and meets the following 
qualifying Medicare Conditions of Coverage provisions as specified in 42 CFR 403.720.  
To qualify as a Medicare or Medicaid RNHCI an institution must meet all ten of the 
following requirements: 
 
  Is described in subsection (c)(3) of 501 of the Internal Revenue Code of 1986 and 
is exempt from taxes under subsection 501(a); 
 
  Is lawfully operated under all applicable Federal, State, and local laws and 
regulations; 
 
  Furnishes only nonmedical nursing items and services to beneficiaries who choose 
to rely solely upon a religious method of healing, and for whom the acceptance of 
medical services would be inconsistent with their religious beliefs.  (NOTE: 
Religious components of the healing are not covered);  
 
  Furnishes nonmedical items and services exclusively through nonmedical nursing 
personnel who are experienced in caring for the physical needs of nonmedical 
patients.  For example, caring for the physical needs such as assistance with 
activities of daily living; assistance in moving, positioning, and ambulation; 
nutritional needs; and comfort and support measures; 
 
  Furnishes nonmedical items and services to inpatients on a 24-hour basis; 
 
  Does not furnish, on the basis of religious beliefs, through its personnel or 
otherwise, medical items and services (including any medical screening, 
examination, diagnosis, prognosis, treatment, or the administration of drugs) for its 
patients; 
 
  Is not owned by, under common ownership with, or has an ownership interest of 5 
percent or more in, a provider of medical treatment or services and is not affiliated 
with a provider of medical treatment or services or with an individual who has an 
ownership interest of 5 percent or more in a provider of medical treatment or 
services (permissible affiliations are described in 403.738(c)); 
 
  Has in effect a utilization review plan that meets the requirements of 
403.720(a)(8); 
 
  Provides information CMS may require to implement 1821 of the Act, including 
information relating to quality of care and coverage determinations; and    
  Meets other requirements CMS finds necessary in the interest of the health and 
safety of the patients who receive services in the institution. 
 
2054.1A - Other Medicare Conditions of Coverage 
(Rev. 1, 05-21-04) 
 
The remaining Conditions of Coverage are specific to Medicare; however, a State may 
elect to employ any or all of these requirements within their optional Medicaid State plan 
amendment. 
 
2054.1B - Valid Election Requirements 
(Rev. 1, 05-21-04) 
 
The regulations at 42 CFR 403.724 present the elements necessary for a Medicare 
beneficiary to complete an election to receive care in an RNHCI.  The RO determines 
whether or not the RNHCI has adequately ensured that the Medicare beneficiarys valid 
election statement has been included with the RNHCIs administrative records and/or 
patient care records. 
 
NOTE:  The facility is to provide the fiscal intermediary the original of the election 
statement, which will be used for each Medicare beneficiary in the RNHCI and retain a 
copy in its files. 
 
The provisions for valid elections include the following general requirements:  
 
  The election statement must be made by the Medicare beneficiary or by his or 
her legal representative.  It must include written statements that: 
 
o  The beneficiary is conscientiously opposed to acceptance of nonexcepted 
medical treatment; 
 
o  The beneficiary acknowledges that acceptance of nonexcepted medical 
treatment is inconsistent with his or her sincere religious beliefs; 
 
o  The beneficiary acknowledges that receipt of nonexcepted medical care 
constitutes a revocation of the election and may limit further receipt of 
services in an RNHCI;  
 
o  The beneficiary acknowledges that the election may be revoked by 
submitting a written statement to CMS; and  
 
o  The beneficiary acknowledges that the revocation will not prevent or delay 
access to medical services available under Medicare Part A in other types 
of facilities. 
 
A valid election must also:   
  Be signed and dated by the beneficiary or by his or her legal representative, not 
prior to reaching Medicare eligibility and beneficiary status; 
 
  Be notarized; 
 
  Include an original copy submitted on file to CMS  (CMS is represented for this 
purpose by the intermediary); and 
 
  Include any other information obtained regarding prior elections or revocations. 
 
A beneficiarys election is revoked by one of the following:  
 
  The beneficiary receives nonexcepted medical treatment for which Medicare 
payment is made; or 
 
  The beneficiary voluntarily revokes the election and notifies CMS in writing. 
 
NOTE:  Excepted and nonexcepted medical care are defined are defined in 42 CFR 
403.702.  The receipt of excepted medical care or treatment as defined in 403.702 does not 
revoke the election made by a beneficiary. 
 
The beneficiarys ability to elect is limited once the election has been made and revoked 
twice (see 403.724(c)). 
 
Organ Transplant Programs 
 
2060 - Organ Transplant Programs  
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
2060A  Citations 
 
The Conditions of Participation (CoPs) for Transplant Centers were established under 
several statutory authorities. Section 1102 of the Social Security Act (the Act) 
authorizes the Secretary to publish rules and regulations necessary for the efficient 
administration of the functions with which the Secretary is charged under the Act. 
Section 1871(a) of the Act authorizes the Secretary to prescribe such regulations as 
may be necessary to carry out the administration of the insurance programs under this 
title. Section 1881(b)(1) of the Act contains specific authority for prescribing the 
health and safety requirements for facilities, including renal transplant centers, that 
furnish end stage renal disease (ESRD) care to beneficiaries.  Section 1861(e)(9) of the 
Act authorizes developing standards necessary for the health and safety of individuals 
furnished services in hospitals.  Organ transplant programs are required to be in 
compliance with the federal requirements set forth in the Medicare CoPs in order to be 
eligible to receive Medicare payment.  In addition to meeting the CoPs for Transplant 
Centers in 42 CFR Part 482, Subpart E, transplant programs must also meet the 
Hospital CoPs specified in 482.1 through 482.57.  2060B  DEFINITIONS 
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
2060B-1 Organ Procurement and Transplantation Network (OPTN) 
 
The OPTN is a public-private partnership that links all professionals involved in the 
donation and transplantation system.  The OPTN operates the national network for 
organ procurement and allocation and works to promote organ donation.  The OPTN 
was established by the National Organ Transplant Act of 1984 and is operated by 
United Network for Organ Sharing (UNOS) under a contract from the Health 
Resources and Services Administration (HRSA) in accordance with section 372 of the 
Public Health Service (PHS) Act.  Through its policies, the OPTN works to increase 
the number of transplants, provide equity in access to transplants, improve outcomes 
for waitlisted patients, living donors and transplant recipients, and promote living 
donor and transplant recipient safety. 
 
2060B-2 Scientific Registry of Transplant Recipients (SRTR) 
 
The SRTR, founded in 1987, is a national database of transplant statistics that 
provides analytic support for the ongoing evaluation of the scientific and clinical 
status of solid organ transplantation in the United States.  It was established pursuant 
to section 373 of the PHS Act. 
 
2060C - Regulatory Background 
 (Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
The Conditions of Participation for transplant programs were published in the Federal 
Register on March 30, 2007 (72 FR 15198) and became effective 90 days after 
publication on June 28, 2007. 
 
2061  Request for Medicare Approval of an Organ  
Transplant  Program  
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 
06-14-19) 
 
Effective January 1, 2019, transplant programs seeking to participate in the Medicare 
program must submit a request for Medicare approval to the applicable State Survey 
Agency and not the CMS RO.  The SA will provide a packet of information to the 
applicant including a list of documents that must be submitted to the SA. 
 
The hospital in which the transplant center is located must submit a revised CMS-
855A to its Medicare Administrative Contractor (MAC) to indicate the addition of a 
service. 
 
  2061A Programs Serving both Adult and Pediatric Populations 
 
A transplant program can apply for and be approved for both an adult (age 18 and over) 
and a pediatric (under age 18) transplant program for the same organ type.  They can apply 
to be approved separately, but are not required to do so. 
 
If a transplant program is seeking separate approval of its adult and pediatric programs, 
the programs will be surveyed separately.  If a program seeks a single approval for both 
age groups, the program must apply for the primary age group that it serves.  That is, a 
program that provides more than 50 percent of its transplants in a 12-month period to 
pediatric patients must apply as a pediatric program.  A program that provides more than 
50 percent of its transplants in a 12-month period to adults must apply as an adult program. 
 
2061B Organ Procurement and Transplantation Network Membership 
 
Membership in the OPTN by the transplant hospital in which the transplant program is 
located is a requirement for Medicare approval. 
 
2062 - Survey and Approval Procedures for Organ 
Transplant Programs  
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 
06- 
14-19) 
 
2062A - The Transplant Program Quarterly Report (TPQR) 
 
The TPQR is a pre-survey report generated by CMS.  It conveys information from 
transplant program data received from the SRTR and the OPTN.  The TPQR includes: 
  Types of transplant programs; 
  Program data including data submission, clinical experience (the number 
of transplants performed) and program outcomes for patient and graft 
survival. 
 
During pre-survey, the survey team reviews the TPQR to determine the number of 
surveyors that will be indicated based upon the number of programs that will be 
reviewed.  The team also identifies any non-compliance with the requirements of 
482.80 and 482.82.  Any non- compliance identified during the pre-survey will be 
communicated to the applicable program at the entrance conference of the survey.  
There is no additional survey activity required regarding the TPQR. 
 
During the process of the transplant program survey, the surveyors review compliance 
with both the transplant program and general hospital regulations.  If a deficiency with 
the hospital requirements is identified in the hospital in which the transplant program is 
located and that hospital is a deemed provider, the surveyor, (or their management) 
must contact the applicable CMS Regional Office for approval to investigate and cite 
the deficiency on a hospital survey report.   
 
2062B Types of Surveys and Related 
Guidance 
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
2062B.1 Initial Survey for Medicare Approval 
 
Once the MAC notifies the SA/RO of its approval of the revised CMS-855A, a survey 
may be scheduled.  Initial surveys are unannounced.  If the applicant transplant 
program is found to be in compliance with the CoPs, it is assigned a CCN.  The 
program will not be issued a separate provider agreement.  Once transplant program 
approval is completed, the RO will forward a form CMS-2007 (Provider Tie-In Notice) 
to the MAC.  In order for CMS to make a compliance determination with 482.80, the 
applicant must have submitted sufficient data to the SRTR for CMS to review. 
 
2062B.2 Re-
approval Surveys  
 
Once a transplant program has been approved to participate, it will be periodically re-
surveyed for compliance with the CoPs.  Re-approval surveys are unannounced surveys 
and are performed at a frequency consistent with the CMS Mission and Priority 
Document (MPD). 
 
A transplant program may voluntarily declare an Inactive Status with the CMS 
and may remain inactive and retain its Medicare approval for a period not 
exceeding 12 months under 488.61(e).  The program must provide immediate 
written notification to its SA of the anticipated inactivity period.  Notification to the 
SA and to the potential recipients must occur prior to the beginning of the planned 
inactivity period.  During its inactivity period, the program must continue to 
comply with all of the Medicare CoPs and routine surveys or complaint 
investigations should not be delayed based on an Inactive Status. During survey 
activity either during the inactive status or following an inactive status, the 
surveyor should determine that: 
 
  The patients on the waitlist during the period of inactivity were notified of 
the inactive status; and 
  The notifications were accomplished in a manner consistent with 482.102(c)(3). 
 
2062B.3 Outcomes Non-Compliance 
 
2062B.4 Clinical 
Experience  
 
To be considered for an initial approval, a transplant program must generally perform 
10 transplants over a 12 month period.  If the program performs at least eight  transplants over a 12 month period, it may be approved with an acceptable plan of 
correction. 
 
Currently approved transplant programs must perform at least 10 transplants a year over 
the prior three years.  Programs not meeting this standard should be cited for non-
compliance at the Standard level.  The program may be reapproved with an acceptable 
plan of correction if all other CoPs are in compliance. 
 
2062B.4 Complaint Surveys  
 
See SOM, Chapter 5, for a description of the general complaint investigation process. 
 
For complaint investigations of a transplant program, the scope of survey activities is 
generally limited to the specific transplant CoPs associated with the allegation(s).  If 
allegations are substantiated, the scope may be expanded to review any associated 
CoPs. 
 
Complaints related to disease transmission via an organ from a deceased donor should 
be communicated to the RO for their determination of the need for an OPO complaint 
investigation. 
 
* There must be a formal arrangement between the hospital in which the transplant 
program is located and any other hospital which provides living donor services for the 
transplant program.  It is the transplant programs responsibility to ensure that the 
CoPs applicable to living donors are met by the associated hospital providing the 
living donor services.  The medical record of the living donor must confirm that all the 
requirements of the CoPs were met. 
    2062C - Determining Level of Deficiency for Clinical Experience 
(Volume) and Outcome Requirements Standards: 
(Rev. 190, Issued:06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
Compliance with the clinical experience (volume) standards at 42 CFR 482.80(b) 
and 482.82(b) and the outcome requirements standards at 42 CFR 482.80(c) and 
482.82(c) is determined by reviewing the programs performance compared to the 
objective standards outlined in the regulation.  The goal of this section is to achieve 
consistency in determining the level of a deficiency citation, (i.e., condition level, or 
standard level) under these CoPs.  The information outlined below will be provided to 
surveyors in the TPQR. 
 
Determining the Level of the Deficiency for Non-Compliance with Clinical 
Experience Requirements: 
 
A programs inactivation does not create an exception to the clinical experience 
requirement for the entire 3 year period. 
 
Initial Approval of Transplant Programs under 482.80(b): 
If the transplant program has not performed at least eight transplants in the past 12 
months, a deficiency will be cited at the condition-level deficiency and it will not be 
approved for Medicare participation.  If the program has performed at least eight but 
less than 10 transplants in that time period, a deficiency should be cited at the standard-
level.  The program may still be approved with a standard-level citation for Clinical 
Experience if an acceptable plan of correction is received and the program is in 
compliance with all remaining CoPs.  Kidney programs that have not performed at 
least three transplants in a 12 month period may not be surveyed for initial approval. 
 
Re-approval of Transplant Programs under 482.82(b): 
If the transplant program has performed an average of less than 10 transplants per 
year over the re-approval period (three years), a deficiency should be cited at the 
standard-level.  The program may be re-approved with a standard-level citation for 
Clinical Experience if an acceptable plan of correction is received and the program is 
determined to be in compliance with all remaining CoPs. 
 
The determination of condition-level non-compliance is made based upon the extent of 
non- compliance findings with the standards within a Condition.  A finding of non-
compliance for the Clinical Experience standard alone with no other non-compliance 
within the Condition would generally not result in condition-level non-compliance at 
482.80 or 482.82. 
 
Determining the Level of the Deficiency for Non-Compliance with the 
Outcome Requirements at 42 CFR 482.80(c) and 482.82(c) 
 
Compliance with outcome measures is assessed using data from the most recent 
Center-Specific Report from the SRTR.  Surveyors must utilize the SRTR information 
reported in the TPQR that is provided by the CMS CO.  The SRTR outcome measures  reported in the TPQR are risk- adjusted, 1-year post transplant graft and patient 
survival measures.  The SRTR reports are released every six months and CMS 
compares the results for the programs outcomes to the outcome requirements at 42 
CFR 482.80(c) and 482.82(c) for transplants performed over a 2.5 year window 
(between one year prior and 3.5 years prior to the date the report is published) and 
enters the compliance determination onto the TPQR.  The TPQR identifies the number 
of center- specific SRTR reports in that timeframe that failed to meet the outcome 
requirements.  Surveyors do not conduct the statistical analysis to determine 
compliance nor may the program provide any information to the surveyor on-site to 
change the compliance determination. 
 
The following transplant program types are subject to the outcome requirements: 
 
  Adult Kidney-Only (AKO) 
  Adult Heart-Only (AHO) 
  Adult Lung-Only (ALO) 
  Adult Liver-Only (ALI) 
  Pediatric Kidney-Only (PKO) (includes only 1-year graft survival) 
  Pediatric Heart-Only (PHO) 
  Pediatric Lung-Only (PLO) 
  Pediatric Liver-Only (PLI) 
 
The following transplant program types are not subject to the outcome requirements: 
  Adult Pancreas- (APA) 
  Pediatric Pancreas- (PPA) 
  Adult Intestine/Multivisceral- (AIM) 
  Pediatric Intestine/Multivisceral- (PIM) 
 
Standard  If the most recent SRTR report shows that the program did not meet 
outcome requirements, but none of the four outcome reports prior to the most recent 
one show that the program was out of compliance, a deficiency should be cited at 
the standard-level. 
 
Condition  If the most recent SRTR report shows that the program has not met 
outcome requirements in two consecutive reports and there is either unchanged or a 
decline in outcome data, a deficiency should be cited at the condition-level. 
 
Every six months, CMS CO receives a list of transplant programs that exceed the 
outcomes thresholds for patient and graft survival.  When a program is identified to be 
out of compliance with the measures, CMS CO will notify the provider of its non-
compliance.  More current SRTR data will be reviewed by CMS to determine if the 
program is improving. 
 
At the time of the next bi-annual SRTR report, if a program continues to exceed the 
acceptable patient and graft survival rate, with all thresholds crossed over, more recent 
SRTR data will again be requested and reviewed.  If the more recent data indicates that 
the programs outcomes are not improving, CMS will consider the program to be non- compliant at a condition level and an on-site survey may be scheduled to 
review/identify associated process requirement concerns. 
 
Deficiencies for non-compliance with the outcome requirements, as well as any 
additional deficiencies identified at the time of the on-site survey, will be cited upon 
completion of the survey.  If an on-site survey is not conducted, the program will be 
notified of its non-compliance with the outcome requirements by letter that includes the 
form CMS-2567. 
 
If a transplant program is cited at a condition-level for 482.82, include the following 
language in the letter accompanying the CMS-2567: 
 
The prospective termination date based on noncompliance determination with 42 CFR 
482.82 will be set at 210 days.  This deficiency must be corrected by [Date] in order 
for Medicare approval to continue for the program.  The program has two options for a 
plan of correction for 
482.82: 
 
1.  The program may state that it expects to be back into compliance with 482.82 
within 210 days; or 
2.  The program will apply for mitigating factors review under 488.61(f). 
 
2062D - Post-Survey Activities 
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19)  
 
Following the survey, the surveyor will complete the following forms: 
1) Organ Transplant Hospital Worksheet; 
2) CM 670; 
and  
3) CMS-2567 
 
Once the CMS-2567 is finalized, it will be forwarded to the hospital administrator with 
a request for a Plan of Correction (PoC) if substantial compliance with all the 
requirements was not found.  The SA will review and accept or not accept the PoC.  In 
the case of a finding of Immediate Jeopardy, see Section 3010B of the SOM for a 
description of the special procedures to be followed. 
 
Plan of Correction Transplant Centers 
The PoC should include plans for completion of corrective actions at a maximum of 90 
days. 
 
The PoC for all deficiency citations, with the exception of 482.80 or 482.82, must 
indicate projected correction within 90 days from the receipt of the notification of non-
compliance.  The plan of correction for 482.80 or 482.82 must indicate whether the 
provider intends to submit mitigating factors to CMS.  Prior to the 90th day follow-up  by the SA should occur.  If the provider has not been determined to have achieved 
compliance with the CoPs (other than 
482.80 or 482.82), the program approval must be terminated. 
 
    2062E - Transmission of Program Approval 
Information  
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19)  
 
The RO will assign one CMS Certification Number (CCN), within the 9800 series, to 
all transplant programs operating within a single hospital.  The Medicare approval date 
for the individual program will be determined as follows: 
 
  When there are no deficiencies cited, the approval date is the last date of the 
survey. 
  When there are standard-level deficiencies cited, the approval date is the date 
on which an acceptable Plan of Correction was received by the SA. 
  When there are condition-level deficiencies cited, the approval date is the date 
on which the transplant program is determined to be back in compliance either 
through a revisit or, as determined by the CMS based on the approval of 
mitigating factors. 
 
2062F-Mitigating Factors  
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19) 
 
2062F.1 Medicare Approval Based on Mitigating 
Factors  
 
Under 488.61(f), a transplant program may request that CMS consider mitigating 
factors in the initial approval and re-approval of a transplant program that does not 
meet the CoPs at 482.80 or 482.82.  Mitigating factors will not, however, be 
considered in situations of immediate jeopardy. 
 
488.61(f)(1) describes the general areas that will be reviewed in determining whether a 
program can be initially approved or re-approved based on mitigating factors.  These areas 
include (but are not limited to): 
 
1.  The extent to which outcome measures are not met or exceeded; 
2.  The availability of Medicare-approved transplant centers in the area; 
3.  Extenuating circumstances (such as natural disasters) that may have a 
temporary effect on the program; 
4.  Program improvements that substantially address root causes of graft failures 
or patient deaths, that have been implemented and institutionalized on a 
sustainable basis, and that are supported by outcomes more recent than the 
latest available SRTR report, for which there is a sufficient post-transplant 
patient and graft survival period and a sufficient number of transplants such 
that CMS finds that the program demonstrates present-day compliance with 
the requirements at 482.80(c)(2)(ii)(C) or 
482.82(c)(2)(ii)(C); 
5.  Whether the program has made extensive use of innovative transplantation 
practices relative to other transplant programs, such as a high rate of  transplantation of individuals who are highly sensitized or children who have 
undergone the Fontan procedure, where CMS finds that the innovative 
practices are supported by evidence- based, published research or nationally 
recognized standards or Institutional Review Board (IRB) approvals, and the 
SRTR risk-adjustment methodology does not take the relevant key factors 
into consideration; and 
6.  If the programs performance, based on the OPTN method of calculating 
patient and graft survival, is within the OPTNs thresholds for acceptable 
performance  and  does  not  flag  OPTN  performance  review  under  the 
applicable OPTN policy. 
 
2062F.2 Mitigating Factors Application and Review 
Process  
 
A.  Intent to Apply for Review of Mitigating Factors 
 
1.  The program must state on the CMS-2567, which is submitted to the SA that 
it will apply for mitigating factors as its plan of correction (POC) for non-
compliance  with  data  submission,  clinical  experience,  or  outcomes 
noncompliance. 
2.  Upon receipt of a POC that includes an intent to apply for mitigating factors 
by the provider, the SA will provide a copy of the POC to the CMS CO 
mailbox at QSOG_TransplantTeam.cms.hhs.gov and the SA will refer the 
provider to 488.61(f) for the list of the information that should be submitted 
for the mitigating factors application. 
 
B.  Applying for Mitigating Factors 
 
All information necessary for consideration of mitigating factors must be 
received within 120 calendar days of receipt of the formal written notification of 
noncompliance at482.80 or 482.82.  Failure to submit a complete and timely 
application within 120 calendar days may be the basis for denial of mitigating 
factors.  See 488.61(f) for the materials required for a mitigating factors 
application. 
 
A request for consideration of mitigating factors must include sufficient 
information to permit an adequate review of the transplant program, factors that 
have contributed to outcomes, program improvements or innovations that have 
been implemented or planned, and in the case of natural disasters, the recovery 
actions planned. 
 
The provider must submit the specific information requested by CMS for 
review.  Information and documents submitted for mitigating factors review 
must have all Personally Identifiable Information (PII) removed prior to its 
submission. 
 
C.  The CMS Process for Reviewing Requests for Approval Based on  Mitigating Factors 
 
The CMS CO reviews all requests for mitigating factors review.  It will include 
analysis by  CMS staff  with programmatic and clinical expertise for  each 
transplant program and will be conducted on a case-by-case basis in accordance 
with 488.61. 
 
D. CMS Determination 
 
According to 488.61(g)(1)(i)-(iii), CMS has three options after 
considering applications for mitigating factors.  CMS may: 
 
1.  Approve or re-approve a programs request for approval 
based on the consideration of mitigating factors; 
2.  Deny the programs request for approval or re-approval 
based on the consideration of mitigating factors; or 
3.  Offer the program an opportunity to enter into a time-limited 
Systems Improvement Agreement (SIA) with CMS, under 
certain conditions. 
 
2062 F.3 Processing Medicare Approval based on 
Mitigating Factors  
 
If a request for approval based on a mitigating factors application is approved, the 
condition- level non-compliance under 482.80 or 482.82 is rescinded and the 
prospective termination date is rescinded.  Generally: 
1.  The CO will send an approval letter for mitigating factors to the program with 
a copy to the SA and RO. 
2.  The RO will send an approval letter (if it is an initial application) or a letter 
that removes the prospective termination date (if it is already a Medicare-
approved transplant program). 
3.  The SA/RO will enter an offsite revisit survey into ASPEN and the RO will 
document the programs approval based on the presence of mitigating factors. 
4.  The approval based on mitigating factors does not carry forward to future re-
certification periods, and CMS may remove approval based on mitigating 
factors at any time if improvements are not sustained, subject to prior notice to 
the program and an opportunity to reply. 
 
2062 F.4 Processing Denial of a Mitigating Factors 
Request  
 
CMS will deny approval based on mitigating factors if it finds that a basis for approval 
consistent with 488.61(f) has not been adequately established by the transplant 
program. 
 
If a mitigating factors request is denied, CMS CO will send a letter to the program  communicating its denial of the mitigating factors request and copy of that letter will 
be sent to the SA and RO. 
 
2062 F.5 Systems Improvement Agreements 
(SIA)  
 
When a transplant program has condition-level non-compliance with the CoP 
requirements at 
482.80 or 482.82 triggering a pending termination date, CMS may extend the 
termination date and offer the hospital the opportunity to enter into a time-limited 
Systems Improvement Agreement (SIA) with CMS.  A SIA is a binding agreement that 
may be offered by CMS pursuant to 488.61(h).  The SIA is entered into voluntarily by 
the hospital.  Under an SIA, CMS extends the prospective Medicare termination date 
and offers the program additional time to achieve compliance with the CoPs, contingent 
upon the hospital's agreement to participate in a structured regimen of quality 
improvement activities, to demonstrate improved outcomes, and to waive their right to 
appeal the noncompliance determination leading to the termination. 
 
To be considered for a SIA, the program must demonstrate that it has developed, 
implemented, and evaluated interventions that are designed to address root causes that 
are institutionally supported by the hospitals governing body on a sustainable basis and 
has requested more time for further improvements or demonstrate compliance with the 
outcome requirements.  SIAs include a mechanism for monitoring the program to 
ensure that the terms of the SIA are being met and program efforts to undertake targeted 
and systemic improvements to ensure ongoing and sustainable compliance with the 
regulatory requirements are occurring. 
 
The SIA is signed by program individuals who have the authority to commit the 
hospital to the terms of the Agreement.  The Agreement is between CMS and the 
transplant hospital. 
In  exchange  for  the  additional  time  to  initiate  or  continue  activities  to  achieve 
compliance with the CoPs, the hospital must agree to a regimen of specified activities, 
including (but not limited to) all of the following: 
(i) Peer Review: An external independent peer review team that conducts an onsite 
assessment of the program.  The peer review must include 
(A) Review of policies, staffing, operations, relationship to hospital services, and 
factors that contribute to program outcomes; 
(B) Both verbal and  written feedback provided directly to the 
hospital;  
(C); and 
(D) Onsite review by a multidisciplinary team that includes a transplant surgeon  with expertise in the relevant organ type(s), a transplant administrator, an 
individual with expertise in transplant QAPI systems, a social worker or 
psychologist or psychiatrist, and a specialty physician with expertise in 
conditions particularly relevant to the applicable organ types(s) such as a 
cardiologist, nephrologist, or hepatologist.  Except for the transplant surgeon, 
CMS may permit substitution of one type of expertise for another individual 
who has expertise particularly needed for the type of challenges experienced by 
the program, such as substitution of an infection control specialist in lieu of, or 
in addition to, a social worker. 
(iii) Action Plan: An action plan that addresses systemic quality improvements and 
is updated after the onsite peer review; 
(iv) Onsite Consultant: An onsite consultant whose qualifications are approved by 
CMS, and who provides services for eight (8) days per month on average for the 
duration of the agreement, except that CMS may permit a portion of the time to be 
spent offsite and may agree to fewer consultant days each month after the first three (3) 
months of the SIA.  The function of the onsite consultant is established under the 
discretion of the program. 
(v) Policy & Procedures Review: A comparative effectiveness analysis that 
compares policies, procedures, and protocols of the transplant program with those of 
other programs in areas of endeavor that are relevant to the center's current quality 
improvement needs; 
(vi) Outcomes Data Proficiency: Development of increased proficiency, or 
demonstration of current proficiency, with patient-level data from the SRTR and the use 
of registry data to analyze outcomes and inform quality improvement efforts; 
(vii) Staffing Review: A staffing analysis that examines the level, type, training, and skill 
of  staff in order to inform transplant center efforts to ensure the engagement and 
appropriate training and credentialing of staff; 
(viii) QAPI: Activities to strengthen performance of the QAPI program to ensure full 
compliance with the requirements of 482.96 and 482.21; 
(ix) Monthly Dialogue: Monthly (unless otherwise specified) reporting with 
designated monitor regarding the status of programmatic improvements, 
results of the deliverables in the SIA, and the number of transplants, deaths, 
and graft failures that occur within one (1) year post- transplant; and 
(x) Other: Additional or alternative requirements specified by CMS, tailored to the 
transplant program type and circumstances. 
The content elements under (v), (vi), (vii), or (viii) above may be waived if CMS finds 
that the program has already adequately conducted the activity, the program is already 
proficient in the function, or the activity is clearly in applicable to the deficiencies that 
led to the SIA. 
 
When CMS has offered a SIA to a transplant program, and the program agrees to enter  into it, the following occurs: 
 
1.  CMS develops the initial draft of the proposed SIA, based on (i)-(x) above, and 
forwards the draft to the program for review and comment; 
 
2.  CMS reviews the programs comments and provides feedback regarding any 
changes to the SIA; 
 
3.  CMS and the program will negotiate the final SIA document. 
 
4.  CMS completes the final SIA and forwards it to the program for signature.  
The SIA becomes effective on the date CMS signs the agreement. 
 
2063 - Relationship Between the Transplant CoPs and Hospital CoPs. 
(Rev. 190, Issued: 06-14-19, Effective: 06-14-19, Implementatiom: 06-14-19)  
 
The transplant program must be in compliance with all hospital CoPs as well as all 
transplant program CoPs.  Certain hospital requirements are inherently included in the 
transplant program survey process.  When hospital requirements are thought to be out 
of compliance and in need of investigation the transplant program survey team must 
contact their supervisor to consult with the CMS RO for further instructions on citing 
the hospital deficiencies and must notify the hospital administration of any such 
citation. 
 
The transplant program and hospital survey findings are documented on separate 
CMS-2567 forms even though the surveys are conducted together. 
                      
 
                   Hospices 
 
2080 - Hospice - Citations and Description 
(Rev. 1, 05-21-04) 
 
 
2080A - Citations 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
Section 1861(u) of the Act establishes hospices as a provider of services.  Section 
1861(dd) of the Social Security Act (the Act) defines hospice care and the hospice 
program.  42 CFR 418 sets forth the Conditions of Participation (CoPs) that hospices must 
meet and applies to a hospice as an entity as well as to the services provided to each 
individual under hospice care.  42 CFR Part 418.110 is a condition applicable only to 
hospices that provide short-term inpatient care and respite care directly, rather than under 
arrangements with other participating providers.  Section 1866(a)(1)(Q) of the Act 
requires hospices, among other providers, to file an agreement with the Secretary to 
comply with the requirements found in Section 1866(f) of the Act regarding advance 
directives.   
The Centers for Medicare & Medicaid Services (CMS) has a Web site for survey and 
certification information including hospice policy memos, the State Operations Manual, 
2080-2089 relating to hospices, and Appendix M, Hospice Survey Procedures and 
Interpretive Guidelines.  This information is available at 
http://www.cms.hhs.gov/SurveyCertificationGenInfo/ 
 
Definition 
 
A hospice is a public agency or private organization or a subdivision of either of these that 
is primarily engaged in providing care and services to terminally ill individuals, meets the 
CoPs for hospices, and has a valid Medicare provider agreement.  The law governing the 
provision of Medicare hospice services is found at Section 1861(dd) of the Act.  The law 
further clarifies that terminally ill individuals are individuals having a medical 
prognosis that the individuals life expectancy is 6 months or less.  This definition is 
further clarified at 42 CFR 418.3 to provide for a life expectancy of 6 months or less if 
the illness runs its normal course.  Although the law does not explicitly define its 
expectations for primarily engaged, CMS has interpreted it to mean exactly what it says, 
that a hospice provider must be primarily engaged in providing hospice care and services 
(Section 1861(dd)(2)(A)(i)).  Primarily does not mean exclusively.  This requirement 
does not preclude the hospice from providing services to terminally ill individuals who 
have not elected the hospice benefit or providing services to individuals who are not 
terminally ill, as long as the primary activity of the hospice is the provision of hospice 
services to terminally ill individuals and the hospice meets all requirements for 
participation in Medicare. 
 
Hospice Benefit Periods 
 
An individual may elect to receive Medicare hospice benefits for two periods of 90 days 
and an unlimited amount of periods for 60 days each.  (See 42 CFR 418.21.) 
 
Eligibility Requirements 
 
In order to be eligible to elect hospice care under Medicare, an individual must be entitled 
to Part A of Medicare and be certified as being terminally ill. (See 42 CFR 418.20.)  An 
individual is considered to be terminally ill if the individual has a medical prognosis that 
his or her life expectancy is 6 months or less if the illness runs its normal course. 
 
Referrals may come from any source, but patients must be assessed by the hospice 
medical director for appropriateness of admission in consultation with the patients 
attending physician (if the individual has one).  The hospice medical director must 
consider the diagnosis of the terminal condition of the patient, other health conditions, 
whether related or unrelated to the terminal illness, and current clinically relevant 
information supporting all diagnoses.  The medical director may consult with the attending 
physician directly or through information obtained indirectly.  Information could be 
obtained through the hospice nurse or others who would bring the attending physicians 
knowledge of the patient to the medical director when the admission decision is being  made. 
 
The hospice must obtain written certification of terminal illness within 2 calendar days for 
each of the benefit periods listed in 42 CFR 418.21, even if a single election continues in 
effect for an unlimited number of periods.  If the hospice cannot obtain the written 
certification within 2 calendar days, after a period begins, it must obtain oral certification 
within 2 calendar days and written certification before a claim for payment is submitted. 
 
For the initial 90-day period, certification of terminal illness must be obtained from the 
medical director of the hospice or the physician member of the hospice interdisciplinary 
group (IDG) and the individuals attending physician (if the individual has one).  
Recertification for subsequent periods only requires the certification of the hospice 
medical director or the physician member of the IDG.  Certification statements must be on 
file and dated by the physician before the hospice submits a claim for payment.  (See 42 
CFR 418.22.) 
 
2080B - Description 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
Hospice care means a comprehensive set of services described in Section1861(dd)(1) of 
the Act, identified and coordinated by the individuals attending physician, medical 
director and by an interdisciplinary group to provide for the physical, psychosocial, 
spiritual and emotional needs of a terminally ill patient and family members, as delineated 
in a specific patient plan of care. 
 
Hospice uses an interdisciplinary approach to caring for terminally ill individuals that 
stresses palliative care as opposed to curative care.  Palliative care means patient and 
family-centered care that optimizes quality of life by anticipating, preventing, and treating 
suffering.  Palliative care throughout the continuum of illness involves addressing 
physical, intellectual, emotional, social, and spiritual needs and facilitating patient 
autonomy, access to information, and choice.  The emphasis of hospice care is on effective 
symptom management, with the goal of making the patient as physically and emotionally 
comfortable as possible, and enabling the patient to remain at home as long as possible 
with minimal disruption to normal activities.  Counseling and respite services are available 
to the family of the hospice patient.  Hospice considers both the patient and the family as 
the unit of care. 
 
Although some hospices are located as part of a hospital, skilled nursing facility (SNF), 
and home health agency (HHA), hospices must meet specific CoPs and be separately 
certified and approved for Medicare participation as a hospice provider of services.  (See 
Exhibit 129 for Hospice Survey and Deficiencies Report, Form CMS-643, and Exhibit 
72 for Hospice Request for Certification in the Medicare Program, Form CMS-417.) 
 
2080C - Hospice Core Services 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
With the exception of physician services, substantially all core services must be provided  directly by hospice employees on a routine basis.  These services must be provided in a 
manner consistent with acceptable standards of practice.  The following are hospice core 
services: 
 
  Physician services; 
 
  Nursing services, (routinely available and/or on call on a 24-hour basis, 7 days a 
week) provided by or under the supervision of a registered nurse (RN) functioning 
within a plan of care developed by the hospice (IDG) in consultation with the 
patients attending physician, if the patient has one; 
 
  Medical social services by a qualified social worker under the direction of a 
physician; and 
 
  Counseling (including, but not limited to, bereavement, dietary, and spiritual 
counseling) with respect to care of the terminally ill individual and adjustment to 
death.  The hospice must make bereavement services available to the family and 
other individuals identified in the bereavement plan of care up to 1 year following 
the death of the patient. 
 
The hospice may contract for physician services as specified in 42 CFR 418.64(a). 
 
A hospice may use contracted staff, if necessary, to supplement hospice employees in 
order to meet the needs of patients under extraordinary or other non-routine 
circumstances. 
 
2080C.1 - Waiver of Certain Staffing Requirements 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
Hospices are prohibited from contracting with other hospices and non-hospice agencies on 
a routine basis for the provision of the core services of nursing, medical social services 
and counseling to hospice patients.  A hospice may, however, enter into arrangements 
with another hospice program or other entity for the provision of these core services in 
extraordinary, exigent, or other non-routine circumstances.  An extraordinary 
circumstance generally would be a short-term temporary event that was unanticipated.  
Examples of such circumstances might include unanticipated periods of high patient loads, 
caused by an unexpectedly large number of patients requiring continuous care 
simultaneously, temporary staffing shortages due to illness, receiving patients evacuated 
from a disaster such as a hurricane or a wildfire, or temporary travel of a patient outside 
the hospices service area.  The hospice that contracts for services must maintain 
professional management responsibility for all services provided under arrangement or 
contract at all times and in all settings.  Regulations at 42 CFR 418.100(e) discuss the 
professional management responsibilities of the hospice for services provided under 
arrangement. 
 
Hospices must maintain evidence of the extraordinary circumstances that required them to 
contract for the core services and comply with the following:   
  The hospice must assure that contracted staff is providing care that is consistent 
with the hospice philosophy and the patient's plan of care and is actively 
participating in the coordination of all aspects of the patients hospice care, and 
 
  Hospices may not routinely contract for a specific level of care (e.g., continuous 
care) or during specific hours of care (e.g., evenings and week-ends). 
 
2080C.2 - Contracting for Highly Specialized Services 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
A hospice may contract for the services of a registered nurse if the services are highly 
specialized, provided non-routinely, and so infrequently that the provision of such services 
directly would be impracticable and prohibitively expensive.  Highly specialized services 
are determined by the nature of the service and the nursing skill level required to be 
proficient in the service.  For example, a hospice may need to contract with a pediatric 
nurse if it cares for pediatric patients infrequently, and employing a pediatric nurse would 
be impracticable and expensive.  Continuous care is not a highly specialized service, 
because while time intensive, it does not require highly specialized nursing skills. 
 
 
2080C.3  Hospice Nursing Shortage Provision 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
CMS has instituted a temporary measure for hospices that are unable to hire a sufficient 
number of nurses directly due to the nursing shortage.  During the time period from 
October 1, 2010  September 30, 2012, in order to qualify for an extraordinary 
circumstance exemption, a hospice must notify the state agency (SA) responsible for 
licensing and certification that it intends to elect an exception under the extraordinary 
circumstance authority.  This may be accomplished by providing written notification to 
the SA when it believes that the nursing shortage has become an extraordinary 
circumstance in its ability to hire nurses directly, and it must estimate the number of 
nurses it believes it will currently need to employ under contract.  Notification may be 
made prior to September 30, 2012, and should address the following: 
 
  An estimate of the number of potential patients that the hospice has not been able 
to admit during the past --3 months due to the nursing shortage and provide the 
current and desired patient/nurse ratio for the agency; 
 
  Evidence that the hospice has made a good faith effort to hire and retain nurses, 
including: 
 
-  Copies of recent advertisements (e.g., in local newspapers, Web sites, etc.,) 
that demonstrate recruitment efforts; 
 
-  Copies of reports of telephone contacts with potential hires, professional 
schools and organizations, recruiting services, etc., and   
-  Job descriptions for nurse employees; 
 
  Evidence that salary and benefits are competitive for the area; 
 
  Evidence of any other recruiting activities (e.g., recruiting efforts at health fairs, 
educational institutions, health care facilities, and contacts with nurses at other 
providers in the area); 
 
  Ongoing self-analyses of the hospices trends in hiring and retaining qualified 
staff; and 
 
  Evidence that the hospice has a training program in place to ensure that contracted 
staff are trained in the hospice philosophy, and able to provide palliative care prior 
to patient contact;  
 
Contracted nurses may only be used to supplement the hospice nurses employed directly 
and should not be used solely to provide the continuous nursing level of care or on call 
service.  The hospice is expected to continue its recruitment efforts during the period that 
it is contracting for nurses. 
 
No approval action is required on the SAs part when it receives written notification from 
a hospice for an exemption, as long as the hospice provides the appropriate information.  
The SA will maintain copies of each exception notification and validate the hospices 
stated need for an exemption during complaint and re-certification surveys.  Of particular 
importance will be the extent to which the hospice nurses have been trained in the hospice 
philosophy and are able to effectively provide care to the patients consistent with the 
patient specific plan of care established by the IDG. 
 
NOTE:  CMS has instituted a temporary measure to allow individual hospices to 
contract for nurses until September 30, 2012, if the hospice can 
demonstrate that the nursing shortage is creating an extraordinary 
circumstance that prevents it from hiring an adequate number of nurses. 
 
2080D - Hospice Required Services 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
  
Requirement for 24-Hour Services 
 
The hospice is required by the CoPs at 42 CFR 418.100 to make nursing services, 
physician services, drugs, and biologicals routinely available on a 24-hour basis, 7 days a 
week.  It also has to make all other covered services available on a 24-hour basis, 7 days a 
week, when reasonable and necessary to meet the needs of the patient and family.   
 
In addition to the hospice core services (physician services, nursing services, medical 
social services, and counseling), the following services must be provided by the hospice, 
either directly or under arrangements, to meet the needs of the patient and family:   
  Physical and occupational therapy and speech-language pathology services; 
 
  Hospice aide services  A hospice aide employed by a hospice, either directly or 
under contract, must meet the qualifications required by Section1891(a)(3) of the 
Act and implemented at 42 CFR 418.76; 
 
  Homemaker services; 
 
  Volunteers; 
 
  Medical supplies (including drugs and biologicals on a 24-hour basis) and the use 
of medical appliances related to the terminal diagnosis and related conditions; 
 
  Short-term inpatient care (including respite care and interventions necessary for 
pain control and acute and chronic symptom management) in a Medicare/Medicaid 
participating facility; and 
 
  Continuous home care provided during a period of crisis.  Nursing care may be 
covered on a continuous basis for as much as 24 hours a day during periods of 
crisis, as necessary to maintain the patient at home.  42 CFR 418.204(a) defines a 
crisis as the period in which an individual requires continuous care for as much as 
24 hours to achieve palliation or management of acute medical symptoms.  The 
care provided must require at least 8 hours of care in a 24 hour period, and the care 
must be provided predominantly by a licensed nurse (RN, LVN, LPN).  
Homemaker or hospice aide services or both may also be covered if needed. 
 
Section 1861(dd)(5) of the Act allows CMS to permit certain waivers of the requirements 
that the hospice make physical therapy, occupational therapy, speech language pathology 
services, and dietary counseling available (as needed) on a 24-hour basis.   CMS is also 
allowed to waive the requirement that hospices provide dietary counseling directly.  These 
waivers are available only to an agency or organization that is located in an area which is 
not an urbanized area (as defined by the Bureau of Census) and that can demonstrate to 
CMS that it has been unable, despite diligent efforts, to recruit appropriate personnel.  
These waivers are codified at 42 CFR 418.74. 
 
2080D.1 - Hospice Interdisciplinary Group (IDG) 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
Hospices participating in the Medicare program must use an interdisciplinary approach to 
assessing and meeting the physical, medical, psychosocial, emotional, and spiritual needs 
of the hospice patients and families facing terminal illness and bereavement.  The hospice 
IDG members include, but are not limited to, the hospice physician (doctor of medicine or 
osteopathy) who must be an employee of or under contract with the hospice, registered 
nurse, social worker, and pastoral or other counselor.  The IDG is required to conduct a 
comprehensive assessment of the patient and update the assessment at required time 
points.  In addition, the group, in consultation with the patient's attending physician, if the  patient has one, must prepare a written plan of care for each patient that reflects patient 
and family goals and interventions based on the needs identified in the initial, 
comprehensive, and updated assessments.  The plan of care must include all services 
necessary for the palliation and management of the terminal illness and related conditions. 
 
The attending physician may either be a doctor of medicine or osteopathy or a nurse 
practitioner.  This person is identified by the individual, at the time he or she elects to 
receive hospice care, as having the most significant role in the determination and delivery 
of the individuals medical care.  In the event that a beneficiarys attending physician is a 
nurse practitioner, the hospice medical director and/or physician designee must certify or 
re-certify the terminal illness.  Nurse practitioners cannot certify a terminal diagnosis or 
the prognosis of 6 months or less, if the illness or disease runs its normal course, or re-
certify a terminal diagnosis or prognosis. 
 
The hospice IDG is responsible for developing and maintaining a system of 
communication, coordination, and integration of services that ensures that the plan of care 
is reviewed and updated no less frequently than every 15 calendar days.  It is not 
permissible for either the attending physician or the hospice medical director to provide 
the sole guidance for the plan of care.  The law and regulations require that it be the 
combined work of the IDG. 
 
2081 - Revoking Election of Hospice Care 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
The hospice patient or representative may revoke the patients election of hospice care at 
any time during the election period according to 42 CFR 418.28.  Revocation is a 
voluntary action taken by the patient or representative.  The election of the hospice benefit 
is the beneficiarys choice rather than the hospices choice, and the hospice cannot revoke 
the beneficiarys election.  It is important for the hospice to educate the patient and family 
before the start of care that hospice entails certain limits in the way care will be provided, 
including restrictions on obtaining care outside the care arranged for or provided by the 
hospice, and the patients liability for care received without the hospices involvement.  
The hospice should neither request nor pressure the patient/family or representative in any 
way to revoke his/her election. 
 
2082 - Discharge from Hospice Care 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
Once a hospice chooses to admit a Medicare beneficiary, it may not automatically or 
routinely discharge the beneficiary at its discretion, even if the care promises to be costly, 
inconvenient, or the State allows for discharge under State law.  The situations under 
which a hospice may discharge a patient are addressed in the regulation at 42 CFR 418.26 
and include the following situations: 
 
  The patient moves out of the hospices service area or transfers to another hospice; 
  The hospice determines that the patient is no longer terminally ill; and 
    The hospice determines under a policy set by the hospice for the purpose of 
addressing discharge for cause, that the patients (or other persons in the patients 
home) behavior is disruptive, abusive, or uncooperative to the extent that delivery 
of care to the patient or the ability of the hospice to operate effectively is seriously 
impaired. 
 
The hospice must do the following before it seeks to discharge a patient for cause: 
 
  Advise the patient that a discharge for cause is being considered; 
 
  Make a serious effort to resolve the problem(s) presented by the patients (or other 
persons in the patients home) behavior or situation; 
 
  Ascertain that the patients proposed discharge is not due to the patients use of 
necessary hospice services; and 
 
  Document in the clinical record, the problem(s) and efforts made to resolve the 
problem(s). 
 
Prior to discharging a patient for any reason stated above, the hospice IDG must obtain a 
written physicians discharge order from the hospice medical director.  If a patient has an 
attending physician involved in his or her care, this physician should be consulted before 
discharge and his/her review and decision included in the discharge note. 
 
The  hospice  notifies  its  Medicare  administrative  contractor  (MAC)  and  SA  of  the 
circumstances surrounding the impending discharge.  The hospice should also consider 
referrals  to  other  appropriate  and/or  relevant  state/community  agencies  (i.e.,  Adult 
Protective Services) or health care facilities before discharge. 
 
2083 - Hospice Regulations and Non-Medicare Patients 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
The hospice CoPs apply to all patients of the hospice (Medicare and non-Medicare), with 
the exception of the following regulations, which apply only to Medicare beneficiaries: 
 
  42 CFR 418.100(d) - the continuation of care requirement, and 
  42 CFR 418.108(d) - the 80-20 inpatient care limitation. 
 
In addition, the following CoPs regarding the certification and recertification of terminal 
illness are necessary to determine eligibility for Medicare and Medicaid patients and may 
or may not be a requirement by other payment sources: 
 
  42 CFR 418.102(c); 
  42 CFR 418.104 (a)(5); and 
  42 CFR 418.112 (e)(3)(iii). 
 
2084 - Hospice Inpatient Services  (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
Hospices must make inpatient care available for pain control, symptom management, and 
respite purposes.  This inpatient care may be provided directly by the hospice or indirectly 
under arrangements made by the hospice.  If services are provided under arrangements, 
the hospice must ensure that the services are in full compliance with all applicable 
standards relating to inpatient care found at 42 CFR 418.110 and 42 CFR 418.108. 
 
2084A - Hospice Provides Inpatient Care Directly 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
When the hospice provides inpatient care directly, it may do so either in space that it owns 
or leases or in space shared with a Medicare certified hospital, SNF, or Medicaid certified 
nursing facility (NF). 
 
  If the hospice provides care in its own inpatient facility, the care may be provided 
in space that the hospice either owns or leases from another facility or building.  
The inpatient unit may consist of several beds, a group of beds, or a wing and must 
meet all applicable Federal and State requirements and be surveyed for compliance 
with 42 CFR 418.110 prior to providing inpatient care to patients.  This survey 
includes a Life Safety Code survey (which has currently adopted the 2000 edition 
of the Life Safety Code of the National Fire Protection Association) that must be 
done both at the time of initial certification of the inpatient facility and at the time 
of recertification surveys. 
 
  If the hospice provides care directly with hospice staff in space shared with a 
Medicare-certified Hospital, SNF, or a Medicaid certified NF (for respite care 
only), the SA reviews the agreement and patient files for compliance with 42 CFR 
418.110(b) and 42 CFR 418.110(e) since the location already meets the remaining 
requirements of 42 CFR 418.110 as a Medicare/Medicaid participating facility. 
 
2084B - Hospice Provides Inpatient Services Under Arrangements 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
When the hospice provides inpatient services under arrangements with a Medicare 
participating hospital or SNF, a Medicaid participating NF (for respite care only), or an 
inpatient unit of another Medicare-certified hospice, a separate survey of each site is not 
required.  In these cases, the SA reviews the agreement and patient files to assure that the 
standards in 42 CFR 418.110(b) regarding 24-hour nursing service and 42 CFR 
418.110(e) regarding comfort and privacy of patient and family members are satisfied.  
However, if in reviewing contracts and other documentation (e.g., clinical records, plans 
of care), questions arise concerning the contract arrangements, the SA conducts an onsite 
visit to the institution providing the inpatient services to review the care provided under 
arrangements, not to inspect the facility.  This includes hospitals that are accredited by 
The Joint Commission or the American Osteopathic Association that are providing 
inpatient services under arrangements. 
   
Applicability of Inpatient Care CoP 42 CFR 418.110 
 
Location Where Inpatient Care is Provided  Applicability of Condition 
Hospice freestanding inpatient facility  Survey for compliance with 42 CFR 
418.110. 
Medicare certified hospital or SNF and/or  Survey for compliance with 42 CFR 
Medicaid certified NF (for respite care  418.110(b) and 42 CFR 418.110(e). The 
only.)  institution already meets the remaining 
requirements of 42 CFR 418.110 as a 
Medicare/Medicaid certified hospital or 
SNF/NF. 
 
A hospice freestanding inpatient facility is defined in this context as a facility that is not a 
part of another Medicare/Medicaid certified facility (e.g., hospital or SNF/NF). 
 
2085 - Operation of Hospice Across State Lines 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
When a hospice provides services across State lines each respective State Agency (SA) 
must be aware of and approve the action.  Each SA must verify that applicable state 
licensure, personnel licensure, and other State requirements are met in its respective State. 
 
The provision of services across State lines is appropriate in most circumstances.  Areas in 
which community services, such as hospitals, public transportation, and personnel services 
are shared on both sides of State boundaries are most likely to generate an extension of 
hospice services. 
 
When a hospice provides services across State lines, it must be certified by the State in 
which its CMS certification number (CCN) is based, and its personnel must be qualified in 
all States in which they provide services.  The appropriate SA completes the certification 
activities.  The involved States must have a written reciprocal agreement permitting the 
hospice to provide services in this manner.  The reciprocal agreement must indicate that 
both States are aware of their respective responsibilities for assessing the hospices 
compliance with the CoP within their State.  The agreement should assure that home visits 
are conducted to a sample of all patients, in all States served by the hospice. 
 
The CMS Regional Office (RO) will review the required reciprocal agreement between 
the States to assure that the SA where the practice location resides is assuming 
responsibility for any necessary surveys of the location.  If the SAs are unable to come to 
a reciprocal agreement on assuring the necessary surveys of the location, the location 
should not be approved as a part of the hospice.  The provision of interstate service 
without a written reciprocal agreement could severely undermine the States ability to 
fulfill its statutory responsibilities under Section 1864 of the Act to enforce Medicares 
health and safety requirements.  It is at the discretion of the States to decide whether 
entering into reciprocal agreements is in the best interest of their residents, provider 
markets, and quality assurance and oversight systems.   
Exhibit 289 Model Reciprocal Agreement Survey and Certification  contains a model 
reciprocal agreement document for States to use to assist them in fulfilling their statutory 
responsibility to enforce Medicares health and safety requirements when a hospice 
provides services across State lines. 
 
In States that have a reciprocal agreement in place, providers are not required to be 
separately approved in each State; consequently, they would not have to obtain a separate 
Medicare provider agreement/certification number in each State.  Providers residing in a 
State that does not have a reciprocal agreement with a contiguous State are precluded from 
providing services across State lines. 
 
In the event that the hospice operates in two CMS ROs, the RO responsible for the State in 
which the hospice provider agreement/certification number is based should take the lead 
in assuring that the required survey and certification activities are met. 
 
2086 - Hospice Change of Address 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
It is inherent in the provider certification process that a provider notifies CMS of its intent 
to change the location or site from which it provides services.  Absent such notification, 
CMS has no way of carrying out its statutorily mandated obligation of determining 
whether the provider is complying with applicable participation requirements at the new 
site or location.  It is a longstanding CMS policy that there is no basis for a provider to bill 
Medicare for services provided from a site or location that has not been determined to 
meet applicable requirements of participation.  This guidance is contained in Chapter 3, 
section 3224 of Publication 100-07. 
 
When an existing hospice intends to move from its surveyed, certified location to a new 
site or location, it notifies CMS either directly or through the SA, and, if deemed, it 
notifies its approved national accreditation organization (AO), in writing of the proposed 
change of location.  The provider also notifies its MAC and submits all required 
documentation including an amended Form CMS-855A before CMS approval can be 
granted.  The provider obtains CMS approval of the new address before it provides 
Medicare services from the new address. 
 
Upon receipt of a providers notice and request for approval of the move to the new site or 
location, the RO will carefully evaluate the information, together with any supporting 
documentation from the provider and any other relevant information known to the RO in 
making its decision.  If a decision can be made on the written application and supporting 
documentation, CMS will grant or deny an approval without requiring a survey.  If, 
however, the RO concludes that circumstances warrant a survey to establish whether the 
new address complies with all applicable requirements, CMS will advise the provider and 
will make no further findings until a survey has been completed and submitted to CMS for 
its review.  In either event, CMS will notify the provider of its decision in writing, as 
appropriate.  
  CMS generally will not approve a change of location of a primary hospice with one or 
more previously approved multiple locations if the new location increases the distance 
between the primary hospice location and its previously approved multiple location(s) to a 
point that prevents the hospice from exerting the supervision and control necessary at each 
multiple location to assure that all hospice care and services continue to be responsive to 
the needs of the patient/family at all times and in all settings.  In that event, the application 
for approval of the new location would usually be denied without a survey, and the 
provider would apply for a new certification number for the new location.  Request for 
approval of a proposed change of location of an approved multiple location is handled as a 
request for approval of a new multiple location, in accordance with the regulations and 
guidelines at 42 CFR 418.100(f). 
 
NOTE:  CMS will not approve a change of location for a hospices own inpatient 
facility without a survey to assure that the facility meets all requirements specified at 42 
CFR 418.110. 
 
2086A - Effective Date 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
A hospice may not bill for services provided from the new site or location and should not 
bill Medicare until the new site or location has been approved by CMS.  The effective date 
of coverage for services provided from the new location is the date CMS grants approval 
to the hospices request to change locations.  The fact that a national AO has approved a 
new site or location will not affect CMS decision.  CMS determination will be based on 
its independent application of its regulations to the facts in the case.  Services provided 
before the effective date of approval should not be billed to Medicare. 
 
2086B  Administrative Review 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
CMSs decision on a request for approval of a change of address does not qualify as an 
initial determination subject to administrative review under 42 CFR 498.3.  Such a 
determination does not affect the existing provider agreement, which continues in effect at 
the surveyed, certified location until voluntarily terminated by the provider pursuant to 42 
CFR 489.52 or involuntarily terminated by CMS pursuant to 42 CFR 489.53.  In the event 
approval of the new change of address is denied, the provider has the option of formally 
applying for initial certification of the new site or location as a separate Medicare provider 
of hospice services.  In that event, an initial certification survey by CMS or the SA (or 
accreditation based on survey by a national AO with deeming authority) would be 
required. 
 
2086C  Move after Certification Survey 
(Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) 
 
Requests for initial certification cannot be processed to completion if a prospective 
provider moves to a new location after it is surveyed and/or deemed to meet the CoPs by a 
national AO with deeming authority.   If a prospective provider moves after its location  has been surveyed and/or accredited but prior to a certification determination by CMS, the 
prospective providers application for certification becomes incomplete.  Absent a survey 
of the new location to which the prospective provider has moved, CMS is unable to 
determine whether applicable program requirements are met at the new location, and 
therefore is prevented from completing its review of the pending application.  In these 
circumstances, CMS advises the prospective provider that its application is incomplete.  
Such an incomplete application is held in abeyance pending receipt of a report of survey 
of the current location from the SA or a national AO with deeming authority meeting the 
requirements of and approved by CMS.  The decision to hold an incomplete application in 
abeyance does not qualify as an initial determination as defined in 42 CFR 498.3. 
 
2087 - Simultaneous Surveys 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
If a hospice is established by an entity which participates in the Medicare program as another 
type of provider (hospital, SNF, HHA), the SA should attempt to coordinate simultaneous 
certification surveys of these entities, i.e., for compliance with hospice CoPs and for 
compliance with the other appropriate CoPs/requirements. 
 
NOTE: Section 1861(dd)(4)(A) of the Act states that if a hospice is approved as being part of 
another type of provider, with a separate certification number, it shall be considered to meet 
those CoPs that are common to both the hospice and the other type of provider. 
 
2088  Multiple Locations 
(Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 
 
When an existing hospice intends to add a multiple location, it must notify CMS, the SA, 
and, if deemed, it should notify its approved national AO, in writing, of the proposed 
location if it expects this location to participate in Medicare or Medicaid.  The hospice 
must also submit a Form CMS-855A Change of Information Request (including all 
supporting documentation) to its MAC before CMS approval can be granted.  The 
provider must obtain CMS approval of the new location before it is permitted to bill 
Medicare for services provided from the new location. 
 
Upon receipt of a hospices notice and request for approval of a multiple location, the 
CMS RO will carefully evaluate the information, together with any supporting 
documentation from the hospice and any other relevant information known to the RO in 
making its decision.  If a decision can be made based on the written application and 
supporting documentation, CMS will grant or deny an approval without requiring a 
survey.  If, however, the RO concludes that circumstances warrant a survey to establish 
whether the new location complies with all applicable requirements, CMS will advise the 
provider and will make no further findings until a Medicare certification survey has been 
completed and submitted to CMS for its review.  In either event, CMS will notify the 
provider of its decision in writing, as appropriate. 
 
In evaluating a hospices request for approval of a multiple location, the SA and RO 
should consider the following in determining whether the new location meets all  applicable Medicare requirements:  
 
  Ability of the governing body to manage the location; 
 
  Any changes made to the lines of authority, and professional and administrative 
control; 
 
  Ability of the Medical Director to assume responsibility for the medical 
component of the hospices patient care at all locations; 
 
  Ability of the hospice to monitor and exercise control over services provided by 
personnel under arrangements or contracts at the multiple location; 
 
  Changes in the IDG(s) providing hospice services; 
 
  Changes in staffing or the client population, or both; 
 
  Changes in the way clinical records are maintained, protected and safeguarded 
against loss, destruction or unauthorized use; and 
 
  Ability of the hospice to provide all hospice services at the multiple location. 
 
A hospice may not bill Medicare for services provided from a multiple location until the 
new site or location has been approved by CMS.  The fact that a national AO with 
deeming authority has approved a new site or location will not affect CMS decision.  
CMS determination will be based on its independent application of its regulations to the 
facts in the case.  Services provided before the effective date of approval should not be 
billed to Medicare. 
 
If the hospice does operate at multiple locations, a deficiency found at any location will 
result in a compliance issue for the entire hospice. 
 
For further information on hospice multiple locations, see 42 CFR 418.100(f) and 
418.116. 
 
2089  Survey Requirements When the Hospice Provides Care to 
Residents of a SNF/NF or ICF/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
When a SNF or NF is the hospice patients residence for purposes of the hospice benefit, 
the SNF or NF must comply with the requirements for participation in Medicare or 
Medicaid.  The Medicare/Medicaid regulations for long term care facilities regarding the 
completion and submission of the Resident Assessment Instrument/Minimum Data Set 
(RAI/MDS) data do not change when the resident elects the Medicare Hospice Benefit.  
This means the SNF or NF must assess the hospice resident using the RAI, and have a 
care plan and provide the services required under the plan of care.  This can be achieved 
through cooperation between the hospice and facility staff with the consent of the resident.   In these situations, the hospice IDG should participate with the facility in completing the 
RAI. 
 
Similarly, the SNF/NF must complete the RAI for any hospice patient who receives short 
term inpatient care in a Medicare/Medicaid participating SNF/NF if the hospice patient 
resides in the facility for more than 14 days.  For further information on the hospice 
requirements when it provides care in these settings, see 42 CFR 418.112. 
    Intermediate Care Facilities 
 
2130 - ICFs/IID  Citations and Description 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
2130A - Citations 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13)  
 
An ICF/IID is defined in 1905(d) of the Act.  The ICF/IID CoPs appear in  
42 CFR Part 483 Subpart I.  Regulatory requirements for ICF/IID services which appear in 
42 CFR 435, Subpart K (Federal Financial Participation) and Part 440 Subpart A 
(Definitions), augment the CoPs listed in 42 CFR Part 483. 
 
2130B - Definitions 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
An ICF/IID is an institution that meets Federal CoPs and has as its primary purpose the 
provision of health or rehabilitation services to individuals with intellectual disabilities or 
related conditions receiving care and services under the Medicaid program. 
 
The ICF/IID CoPs recognize the developmental, social, and behavioral needs of 
individuals with intellectual disabilities who live in residential settings by requiring that 
each individual both require and receive active treatment for the ICF/IID care to be 
eligible for Medicaid funding. 
 
Active treatment means the aggressive, consistent implementation of a program of 
specialized and generic training, treatment, health, and related services directed toward the 
acquisition of the behaviors necessary for the individual to function with as much self-
determination and independence as possible.  It includes the prevention or deceleration of 
regression or loss of current optimal functional status. 
 
An injury should be reported as an injury of unknown source when: 
 
1.  The source of the injury was not witnessed by any person and the source of the 
injury could not be explained by the client; and 
 
2. The injury raises suspicions of possible abuse or neglect because of the extent of 
the injury or the location of the injury (e.g., the injury is located in an area not 
generally vulnerable to trauma) or the number of injuries observed at one 
particular point in time or the incidence of injuries over time. 
 
The definition of immediately means there should be no delay between staff awareness 
of the allegation and reporting to the administrator or other officials in accordance with 
State law unless the situation is unstable at the time the allegation comes to the attention 
of the staff.  In this case, reporting should occur as soon as the safety of all clients is 
assured and all necessary emergency measures have been taken.   
Section 42 CFR  483.420(d)(2) of the ICFs/IID regulations addresses the obligation of 
the facility staff to report allegations of mistreatment, neglect or abuse, and injuries of 
unknown source immediately to the administrator of the facility or to other officials in 
accordance with State law through established procedures. 
 
An injury should be reported as an injury of unknown source when: 
 
1.  The source of the injury was not witnessed by any person and the source of the 
injury could not be explained by the client; and 
 
2. The injury raises suspicions of possible abuse or neglect because of the extent of 
the injury or the location of the injury (e.g., the injury is located in an area not 
generally vulnerable to trauma) or the number of injuries observed at one 
particular point in time or the incidence of injuries over time. 
 
It is important to note that members of the ICF/IID population are a mobile population and 
lead active lives.  Therefore, they experience normal day-to-day bumps and minor 
abrasions as they go about their lives.  These minor occurrences which are not of serious 
consequence to the individual and do not present as a suspicious or repetitive injury (as 
discussed above) should be recorded by the facility staff once they are aware of them and 
follow-up should be conducted as indicated.  For injuries that do not rise to the level of 
reportable injuries of unknown source, the facility should follow its policies and 
procedures for incident recording, investigation, and tracking. 
 
42 CFR  483.420(d)(2) further requires that allegations of mistreatment, neglect or abuse 
and injuries of unknown source must be, reported immediately to the administrator or to 
other officials in accordance with State law, through established procedures.  For the 
purpose of this regulation immediately means there should be no delay between staff 
awareness of the allegation and reporting to the administrator or other officials in 
accordance with State law unless the situation is unstable at the time the allegation comes 
to the attention of the staff.  In this case, reporting should occur as soon as the safety of all 
clients is assured and all necessary emergency measures have been taken. 
 
This reporting must be done on a 24/7 basis.  Conformity with this definition will 
necessitate that the facility administration have procedures in place to receive reports, 
even on off-duty hours (e.g., electronic mail, answering machine, voice mail, and fax).  It 
is critical that the administrator, as designated by the Governing Body under 42 CFR  
483.410(a)(2)-(3), be notified of such occurrences as quickly as possible to ensure the 
safety of all residents.  There must also be evidence that the information was received, in a 
timely manner, by that facility administrator.  When the administrator is not on duty, the 
facility policies and procedures should detail who (either by name or title) will be acting in 
the administrators absence.  The person(s) acting for the administrator must have the 
authority to immediately take whatever corrective action is necessary to ensure client 
health and safety.  For example if an employee is to be removed from client contact 
pending an investigation, the acting administrator must have the authority to take this 
action without approval from another official.   
CMS expects that such reporting is always made to the administrator of the facility (unless 
the administrator is suspected to be involved in the mistreatment, neglect or injury) and 
that the administrator then ensures that the appropriate State officials are notified.  In any 
instance where a staff member is concerned that the administrator of the facility may have 
been involved in an incident of mistreatment, neglect, abuse or injury, the staff member 
should follow the facility policy for reporting to the appropriate person above the level of 
the administrator.  The facility should have a written policy that directs the staff in these 
situations. 
 
2134 - Distinct Part ICF/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Neither the law nor Federal regulations define or require ICF/IID services in terms of 
distinct parts. However, as a State Medicaid program requirement, States may provide for 
distinct part ICF/IID approvals.  Where the SMA elects to define the ICF/IID program in 
terms of distinct parts, these additional Federal provisions must be met: 
 
  The distinct part must be a clearly identified unit, such as an entire ward, wing, 
floor, building, or a number of designated rooms; 
 
  The distinct part consists of all beds and related facilities in the unit; and 
 
  The institution does not need require transfer of patients or individuals to or from 
the distinct part, where, in the opinion of the attending physician, transfer might be 
harmful to the physical or mental health of the patient or individual. Otherwise, the 
unit houses all ICF/IID residents in the institution. 
 
2138 - Approval Procedures for ICFs/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
2138A - Initial Certification of ICF/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Initial certification of ICFs/IID may be granted by the SA only as a result of a complete 
survey which has found the agency to comply with all of the CoPs specified in  
42 CFR 483, Subpart I.  A facility must be operational prior to scheduling an initial 
survey. 
 
Even though a facility may be part of a larger corporation, the fact that it is separately 
certified means that it is an independent institution and must be capable of providing all of 
the services necessary to meet the clients needs. Therefore, the survey of each separately 
certified ICF/IID must ensure that any evidence used in the determination of compliance 
for the requirements stands on its own. 
 
A facility may request that the SA review relevant aspects of its existing immediate track 
record as part of the initial survey process if the following is true. A facility must have  been fully operational as a licensed group home or a distinct part that was never certified 
because of physical plant limitations yet it provided treatment comparable to that required 
by a certified ICF/IID. For example, if the entity claims that it has provided active 
treatment to the same clients who will be certified, with the same staff, and consistent with 
the components of active treatment described in the Federal regulations, then an initial 
survey may be scheduled immediately. To the extent that a survey determines that the 
agencys current and immediate past practices comply with the ICF/IID requirements, the 
SA surveyor may utilize this information in making a compliance determination, as part of 
the survey, but not as a substitution for the survey. 
 
There is no specific number of days that an ICF/IID must be operational prior to its initial 
survey, but in most cases approximately 30-35 days (except as described above) would be 
a general safety measure.  This timeframe, however, is only a recommendation since 
42 CFR Part 483.440(c)(4) only requires that the clients initial individual program plan 
(IPP) must be developed within 30 days after admission.  42 CFR Part 483.440(d)(1) 
requires that as soon as the IPP is developed, each client receives a continuous active 
treatment program.  Therefore, should the facility wish to have its initial survey prior to 
being operational for 30-35 days, it should identify the date by which it will be able to 
demonstrate its compliance with 42 CFR Part 483.440(a) for each of its clients. 
 
Additionally, for an initial survey, a facility may not demonstrate its compliance with 
active treatment based primarily on its policies and procedures. Policies and procedures 
are designed to describe how a facility intends to provide active treatment. This is 
inconsistent with 1905(d)(2) of the Act, which requires that each individual with 
intellectual disabilities for whom a request for payment is made is receiving active 
treatment. 
 
For purposes of the initial survey of an agency in which clients have just moved to the 
agency, the following key components of the active treatment process that are most 
relevant to the survey methodology for the CoP, Active Treatment Services (data tag W 
195; Appendix J) are: 
 
  The comprehensive functional assessment (42 CFR Part 483.440(c)(3)); 
 
  The IPP (42 CFR Part 483.440(c)(4)); 
 
  Program implementation (42 CFR Part 483.440(d)); and 
 
  Program documentation (42 CFR Part 483.440(e)). 
 
It would not be necessary to measure the component of active treatment dealing with 
program monitoring and change (42 CFR Part 483.440(f)) unless it is determined through 
the survey that the initial program clearly does not meet the clients needs and there is no 
evidence of appropriate oversight and attention. 
 
2138B - Multiple Certification of Dispersed Locations 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13)   
When surveying ICFs/IID with more than one unit at dispersed locations, either for an 
initial certification or recertification, the SA surveys each unit. Even if a group of small 
ICFs/IID is centrally administered, the SA prepares a certification package for each unit. 
 
2138C - Minimum Size of ICF/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
An ICF/IID is defined as a facility that furnishes food, shelter, treatment, or services to 4 
or more individuals unrelated to the proprietor.  ICFs/IID vary in size from very large 
multi-unit, multi-level facilities with sophisticated programs to very small, home-like 
settings with required services provided through an arrangement with community 
organizations.  Satellite facilities off the main grounds of an institution are certified as 
separate ICFs/IID. Each must meet the 4-individual minimum. 
 
Not withstanding common ownership or unified administration, a cluster of separate 
facilities in the community cannot be considered as one establishment meeting the 
definition of institution. Separate cluster facilities in the community must be viewed as 
separate establishments.  Each must meet the 4-individual minimum to qualify as an 
institution. 
 
An individual living unit that is part of an overall ICF/IID may be separately certified 
under its own provider number if the living unit meets the criteria for a freestanding 
ICF/IID. Each separately certified facility, at any point in time, must be able to 
independently meet all standards and CoPs. This includes, among other things, 
maintaining independent staffing and management.  Any services which are not provided 
directly by the separately certified facility would have to be provided through a written 
agreement with outside sources as required by 42 CFR Part 483.410(d). 
 
It is unlikely that, for example, a facility with several units housed within one building 
sharing common corridors and utilizing a common kitchen/dining area could meet the 
requirements for maintaining independent staffing and management to meet the criteria for 
a freestanding ICF/IID. 
 
There is no minimum number of individuals who must be in residence at the time of the 
initial survey.  The facility must have enough individuals in residence to demonstrate that 
it is able to, and does in fact, provide services to the total number of individuals it 
proposes to serve.  For example, a facility established to serve 4 individuals would need to 
show capacity to serve 4 people, even though not all 4 people would be required to have 
actually moved in at the time of the initial survey.  (42 CFR Part 435.1009(b)(2) requires 
that a facility serve a minimum of 4 persons in order to meet the definition of an 
institution.) 
 
2138D - Interpretive Guidelines for ICFs/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Guidelines for surveying ICFs/IID are located in Appendix J.  They provide an  interpretation of the ICF/IID regulations that are applicable to all sizes of facilities that 
provide services.  They focus on individual and staff performance rather than on 
compliance with process and paper requirements and reflect current philosophies and 
practices in training individuals with intellectual disabilities and related conditions. 
 
2138E - Survey Report (Form CMS-3070G-I) 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
To survey ICFs/IID, the SA must use the Interpretive Guidelines and Survey Procedures 
(see Appendix J) in conjunction with Forms CMS-3070G-I.  The forms and optional work 
sheet permit the SA to summarize pertinent facility, individual, and survey data, record 
observations about active treatment provided for individuals by staff, and summarize 
deficiency-related data on the standards and CoPs. 
 
In an effort to monitor the number of allegations of abuse and neglect investigated and the 
number of deaths related to restraints and unusual incidents, CMS revised Form CMS-
3070G, the ICF/IID survey report form, to now include an item M - Allegations of 
Abuse and Neglect, to capture this information. All surveys, including initials, 
recertifications, complaints, and follow-ups, occurring after January 2, 2002, must be 
entered into the Online Survey and Certification System (OSCAR). 
 
2138F - Application of LSC to ICFs/IID of 16 Beds or Less 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
When conducting a LSC survey, the SA applies the appropriate occupancy chapter (see 
Appendix I) of the LSC of the National Fire Protection Association (NFPA), 2000 edition. 
 
2138G - Schedule for Recertification 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The SA completes a recertification survey an average of every 12 months and at least once 
every 15 months (see 2141). 
 
2139 - Assessment of ICFs/IID Based on CoPs for Active Treatment 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
To be certified as a Medicaid provider of ICF/IID services, a facility is required by 
1905(d) of the Act to provide active treatment services for each individual for whom 
payment is claimed.  Federal regulations in 42 CFR Part 435.1009 and 483, Subpart I 
outline the requirements for active treatment in ICFs/IID.  While a facility must comply 
with the CoPs to be certified, the SA must place particular emphasis on an assessment of 
whether active treatment is in fact received by individuals for whom payment is claimed.  
Appendix J contains a basic methodology for surveying these requirements. 
 
The definition of active treatment in intermediate care facilities for individuals with 
intellectual disabilities in 42 CFR Part 435.1009 refers to treatment that meets the 
requirements specified in the CoPs for active treatment in 42 CFR Part 483.440(a).  The  components of the active treatment process most relevant to this survey methodology are: 
 
2139A - Comprehensive Functional Assessment 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Within 30 days of admission, the individuals interdisciplinary team must produce 
accurate comprehensive functional assessment data that identifies all her/his present 
problems and disabilities. Also, when possible, their causes; specific developmental 
strengths and needs; behavioral management needs; and the need for services without 
regard to the availability of those services. 
 
  1.  Money Management Program 
 
  Citing Deficiencies: Surveyors currently cite a deficiency during the 
ICF/IID survey process if every client in the facility does not have a formal 
money management program in place. 
 
  Regulatory Provisions: The regulations at 42 CFR 483.420(a)(4) state that 
clients in the ICF/IID must be allowed to manage their financial affairs and 
be taught to do so to the extent of their capabilities. 
 
  Determination of Compliance: The determination as to the 
appropriateness of a formal money management program for an ICF/IID 
client is based upon the results of a comprehensive functional assessment 
and a consensus by the interdisciplinary team. 
 
The need for a formal money management program must be addressed in every 
clients IPP by the IDT on an annual basis.  
 
The determination of the appropriateness of a formal money management program 
is made by the IDT and must be based upon a CFA.  The IDT discussions resulting 
in that determination must be established through documentation in the clients 
IPP. 
 
Surveyors will question and cite any IDT team decision that a formal money 
management program is not appropriate when the client clearly exhibits and the 
CFA supports the skills needed to implement such a program.  
 
  2.  Self-Administration of Medications 
 
It has been the expectation of ICF/IID surveyors pursuant to previous Centers for 
Medicare & Medicaid Services interpretations of 483.460(k)(4), that every client 
residing in an ICF/IID must participate at some level in a formal, self-
administration program for medications. 
 
  Regulatory Requirement for Self Administration Programs:  There is 
no regulation that requires every client to have a formal, self-administration  program for medications.  The appropriateness of such a program for a 
client is determined by the interdisciplinary team in consideration of the 
comprehensive functional assessment data. 
 
  Regulatory Requirement for Those Clients Not in Self-Administration 
Programs:  The concept of continuous active treatment at 483.440(d)(1) 
requires that the facility utilize the time during medication administration 
by staff as a teaching opportunity for clients who have formal training 
programs for the development of skills that are transferrable to the drug 
administration process. 
 
Self administration of medication refers to the intentional, independent application 
or ingestion of over the counter or prescribed medications by an individual without 
assistance, instruction or direction.  The regulation at 483.460(k)(4) requires the 
interdisciplinary team to develop and implement training objectives for 
individuals, determined to be appropriate for self administration of medications 
unless the clients physician specifies otherwise. 
 
The interdisciplinary team must determine, based on comprehensive assessment, 
whether an individual possesses, or has the potential to develop, the requisite skill 
set needed to safely self administer medications and individually tailor training 
objectives to advance the individual toward the goal of self administration. 
 
483.460(k)(4) does not require that all individuals in an ICF/IID be engaged in 
self administration training programs.  The interdisciplinary team decision that a 
self administration program is appropriate, as is the case for all formal training 
objectives, must be based upon accurate, current, valid assessment of the 
individuals skills and potential.  The determination as to the appropriateness of a 
self administration program must never be made singularly on the individuals 
diagnosis or current functional abilities. 
 
For individuals assessed to be inappropriate for a self administration program, but 
determined by the interdisciplinary team to possess the capacity to functionally, 
cognitively, emotionally or developmentally benefit from participation in the drug 
administration process, it is expected that the facility will provide opportunities for 
the client to participate in the medication administration process under direct 
supervision.  This participation can include but is not limited to identifying the 
medication taken, reaching/grasping a cup of water during the process and placing 
oral medications in the mouth, etc. 
 
During drug passes observe whether clients are offered the opportunity to 
participate consistent with their functional skill level and verify that the programs 
are being carried out consistently and in accordance with the written objective.  
For individuals not in need of formal self-administration programs who are not 
provided opportunities to participate in administration process, cite a deficiency at 
483.440(c)(6)(vi). 
  If, as a result of observations and interviews, there are any concerns as to why a client is 
not on a formal program, the surveyor should review the associated assessments and 
interdisciplinary discussions.  During this review look for evidence that the 
interdisciplinary team documented a justification as to why the client was not appropriate 
for a formal self-administration program and that the justification provided was based on 
an evaluation of the assessment results.  Deficiencies for a failure by the facility to 
properly assess, to develop written self administration objectives or to carry out the self-
administration programs consistently should be cited at 483.460(k)(4). 
 
2139B - Individual Program Plan (IPP) 
(Rev. 1, 05-21-04) 
 
The individuals interdisciplinary team must prepare an IPP which identifies the discrete, 
measurable, criterion-based objectives the individual is to achieve; the timetables for 
expected mastery; and the specific individualized program of specialized and generic 
strategies and techniques to be employed. The IPP must be directed toward the acquisition 
of the behaviors necessary for the individual to function with as much self-determination 
and independence as possible and the prevention or deceleration of regression, or loss of 
current optimal functional status. 
 
2139C - Program Implementation 
(Rev. 1, 05-21-04) 
 
Each individual must receive continuous active treatment consisting of needed 
interventions and services in sufficient number and frequency to achieve the IPP 
objectives.  Each individuals IPP must be implemented by all staff working with the 
individual, except where only licensed personnel may implement certain areas of the 
program. 
 
2139D - Program Documentation 
(Rev. 1, 05-21-04) 
 
Accurate, systematic, behaviorally-stated data about an individuals performance toward 
meeting the criteria in the IPP objectives must be documented and serve as the basis for 
changes and revisions, whenever necessary. 
 
2139E - Program Monitoring and Review 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
At least annually, the comprehensive functional assessment of each individual is reviewed 
by the interdisciplinary team for relevancy and updated as needed.  The IPP is revised, as 
appropriate.  The IPP must also be reviewed by a qualified intellectual disabilities 
professional and revised as necessary. 
 
Approximately one-third of the ICF/IID CoPs (42 CFR Part 483, Subpart I) deals with the 
sufficiency and adequacy of staff to deliver each service.  The regulations provide 
guidance about what constitutes active treatment and enable the SA to assess these  standards from the standpoint of whether active treatment is being provided in a consistent 
and aggressive manner. SA entries on both Form CMS-3070G-I and Form CMS-2567 
should reflect this approach. 
 
Of greatest importance in determining if active treatment is being provided is whether the 
facility provides competently trained staff of all types and at all levels who, in fact, do 
implement individually identified objectives established for each individual.  A correct 
certification addresses these objectives in terms of whether the services are being 
delivered to each individual whose IPP indicates that they are needed and whether 
adequate staff and facilities are engaged in furnishing them.  A certification which affirms 
no more than that the services, staff, and facilities are available is incorrect and 
unacceptable.  A provider agreement may be held invalid under 42 CFR Part 483.440(a) 
of the CoPs if the regulation is not correctly applied. 
 
If a facility has the necessary resources available but does not actually provide active 
treatment to individuals in accordance with identified needs or does not conduct the 
comprehensive functional assessment evaluations to identify individuals needs, the SA 
denial, nonrenewal, cancellation, or termination of the agreement is supportable.  The SA 
carefully explains the deficiency in the SA notice of determination. 
 
2140 - Waiver and/or Variance of ICF/IID Requirements 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
2140A - ICF/IID Room Size and Occupancy 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
No waivers are available to an ICF/IID to change the square footage requirements for 
bedrooms. 42 CFR Part 483.470(b) allows as little as 80 square feet for individual 
bedrooms and 60 square feet for multiple individual bedrooms. 
 
However, the SA may grant a variance to the requirement in 42 CFR Part 483.470(b)(iii) 
of no more than four individuals per room if a physician who meets the qualifications for a 
qualified intellectual disabilities professional in 42 CFR Part 483.430(a) and is also a 
member of the individuals interdisciplinary team has justified, in writing, in each IPP, the 
following: 
 
  How the individual is so medically impaired as to require direct and continuous 
monitoring during sleeping hours; 
 
  Whether the individual is on a medical care plan, as described in  
42 CFR Part 483.460(a)(2); 
 
  The extent of life support services needed to meet the individuals medical needs; 
and 
 
  The specific reason why housing the individual in a room of four or fewer 
individuals would not meet the individuals medical needs.   
The variance must not adversely affect the health or safety of the individual. The variance 
must assure that the minimum square footage requirements specified in  
42 CFR Part 483.470(b) have been met.  The variance expires unless renewed each time 
the ICF/IID is certified.  It is not meant to justify the long-term continued use of open 
wards or nominally partitioned wards for housing individuals. 
 
The only acceptable reason for individuals being housed in bedrooms serving more than 4 
individuals is that the individual is in very fragile health and needs extensive life support 
services, such as posturing for clearing the airway, monitoring for uncontrolled seizures, 
etc. Each individual placed in the grouping must have such a high level of medical 
monitoring need as to require supervision which is possible only through the use of 
bedrooms housing more than four individuals. 
 
2140B - Waiver of LSC 
(Rev. 1, 05-21-04) 
 
See 2472. 
 
2141 - Recertification - ICFs/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
  The regulation at 442.15 provides that provider agreements for ICF/IIDs would 
remain in effect as long as the facility remains in compliance with the Conditions Of 
Participation (COPs).  Regulations at 442.109 through 442.111. 
 
  Beginning on May 16, 2012, ICF/IIDs are no longer subject to time-limited 
agreements.  However, they are to be surveyed for re-certification an average of 
every 12 months and at least once every 15 months. 
 
  If during a survey the survey agency finds a facility does not meet the standards for 
participation the facility may remain certified if the survey agency makes two 
determinations  The facility may maintain its certification if the survey agency 
finds Immediate Jeopardy doesnt exist, and if the facility provides an acceptable 
plan of correction. 
 
  An ICF/IID may be decertified under procedures outlined in Section 3012 of the 
State Operations Manual. More specifically, a facility may be decertified if an 
immediate jeopardy finding remains unabated after 23 days or if it fails to regain 
compliance with conditions of participation after 90 days. 
 
ICF/IIDs will be subject to survey an average of every 12 months and at least every 15 
months, the same period that is applied to Nursing Homes. 
 
If a survey agency finds a facility deficient in meeting the standards for ICFs/IID, as 
specified under subpart I of part 483 of chapter 42, the agency may continue 
certification of the facility for Medicaid purposes as long as the agency finds the  facilitys deficiencies do not constitute immediate jeopardy or seriously limit the 
facilitys capacity to provide adequate care.  In addition, the agency must find the 
facilitys plan of correction is acceptable. 
 
The survey agency may conduct a revisit to assure the conditions for continued 
certification are maintained.  A facilitys certification may be terminated according to 
procedures set out in Section 3012 of the State Operations Manual. 
 
2142  Evacuation Drills for ICFs/IID Certified Under the Life Safety 
Code NFPA 101, 2000 Edition 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
  Self-evacuation during an emergency.  Clients residing in ICFs/IID certified under 
Chapter 32/33 of the Life Safety Code NFPA 101, 2000 Edition (LSC) are 
expected to be capable of self-evacuation during an emergency. 
 
  Full evacuation drills- All drills under this Chapter must be full evacuation drills 
unless the facility is designated as evacuation capability, impractical. 
 
  Exceptions to full evacuation drills- With a designation of evacuation capability 
impractical the facility must meet the requirements of Chapter 18/19 of the LSC 
as regards to evacuation drills. 
 
ICF/IID facilities that are certified under Section 32.7.3 or Section 33.7.3 of the LSC must 
conduct emergency drills no less than six (6) times per year on a bi-monthly basis.  These 
drills must all be full evacuation drills and all clients residing in the facility must 
participate in each drill.  At least two of these drills must take place during sleeping hours.  
This requirement is consistent with the requirements of 42CFR 483.470(i)(2)(i) which 
require actual evacuation of clients during at least one emergency drill each year on each 
shift.  
 
ICF/IID facilities certified under Section 32.7.3 or Section 33.7.3 of the LSC with a 
capability classification of impractical must meet the emergency drill requirements 
found at Section 18.7 or Section 19.7 of the LSC.  These sections require that the facility 
conduct fire drills which simulate emergency fire conditions on a quarterly basis.  Since 
these drills are conducted to train staff rather the clients, the Code does not require full 
evacuation.  However, the facility must also meet the ICF/IID regulations at 42CFR 
483.470(i)(2)(i) which do require the actual evacuation of clients during at least one 
emergency drill each year on each shift.  These drills are conducted primarily to prepare 
and train staff and it is critical that the staff from each shift participate in these drills.  The 
facility may not elect to conduct night shift drills during another shift. 
 
The LSC requires that the facility make the determination of impractical utilizing the 
criteria of the Code found in Sections 32/33.2.1.2.2 concerning the characteristics of the 
client population.  The LSC surveyor verifies that the determination was correctly made at 
the time of the annual survey. 
  The requirements of full evacuation during a drill is not intended to address the 
requirements for frequency of evacuation drills.   The regulation at 483.470 (i) requires 
that evacuation/fire drills be conducted at all ICF/IID facilities on a quarterly basis on 
each shift. This requirement supersedes the number of evacuation drills required by the 
LSC under Chapters 32/33 it does not impact the requirements for full evacuation during 
such drills. 
 
2143 - The Use of Video Cameras in Common Areas in ICF/IID 
(Rev.91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
  Use of video cameras in ICFs/IID: To ensure that clients rights are protected, 
the use of video cameras in the ICF/IID must be reviewed, approved and 
monitored by the Specially Constituted Committee (SCC) of the facility as 
constituted per 42 CFR 483.440(f)(3)(i-iii). 
 
  Informed Consent:  If approved by the SCC, written informed consent must be 
obtained from every affected client or designated guardian prior to the 
implementation of video cameras.  Video cameras may be used in common areas 
within the ICF/IID facility. 
 
  Prohibitions: Video cameras may never be used for any reason in areas where 
there are the highest expectations of privacy such as bathrooms, areas for 
private visitation or areas for private phone calls. Video cameras may not be 
used as a substitute for or supplement to adequate staffing or supervision 
protocols.  The cost of the video cameras must be incurred by the facility and 
not the clients. 
 
The Condition of Participation 483.420 requires that the facility must ensure the rights of 
all clients.  Specifically, the facility must: 
 
  ensure that clients are not subjected to physical, verbal, sexual or psychological 
abuse or punishment -483.420(a)(5); 
 
   provide each client with the opportunity for personal privacy and ensure privacy during  
treatment and care of personal needs -483.420(a)(7); and 
 
  ensure clients the opportunity to communicate, associate, and meet privately with  
individuals  of their choice -483.420(a)(9). 
 
The above referenced regulations do not unilaterally prohibit the use of video cameras within 
the ICF/IID.  There may be instances where the use of video cameras may be helpful in 
ensuring that the clients are free from physical, verbal, sexual or psychological abuse, 
mistreatment or punishment.  However, great care must be exercised to prevent any unintended 
violation of an individuals rights and privacy when such equipment is used in the facility. 
 
Consistent with the regulations which require that the ICF/IID provider protect the privacy and 
rights of the clients in the facility, video cameras may only be used in the common areas or  shared spaces of the ICF/IID where clients have lower expectations of privacy and where, in 
the normal course of their day, they may encounter visitors, staff, other clients, or medical 
personnel.  Conversely, video cameras may never be used in areas where the clients have the 
highest expectations of privacy, such as client bathrooms, or areas where residents meet 
privately with visitors or make personal phone calls. 
 
To ensure that any use of  video cameras complies with regulatory requirements that client 
rights are fully protected, any use of video cameras in the ICF/IID must be approved by the 
Specially Constituted Committee (SCC) of the facility as constituted per 483.440(f)(3).  
Affected clients and their families or guardians must be informed of the SCCs approval to 
use video cameras in a specified area.  Written informed consent must be obtained from 
every client or designated guardian living in the physical unit prior to the implementation of 
video cameras.  If an ICF/IID consists of several physically separate living units, and the 
clients (and guardians if applicable) of a single unit have consented to the implementation 
of video cameras, it is not required that the clients residing in the other units (and their 
guardians as applicable) provide informed consent, since they would be considered guests 
when visiting this unit.  However, the facility administration should still inform all clients 
living on the grounds (and their guardians if applicable) that camera use is in place on this 
specific unit. 
 
To ensure the confidential use of the camera recordings, the facility must have policies 
and procedures in place that: 
  a) limit who has access to video viewing or use of the videos; 
b) ensure that all staff with video viewing access are properly trained in the facility 
policies and the protection of client rights; and 
c) ensure that adherence to the facility policies is monitored and that risks or 
breeches of the facility policies are promptly addressed. 
 
The ICF/IID may not utilize video cameras in lieu of adequate staffing or supervision 
protocols.  The use of video cameras must not replace or otherwise substitute for trained 
and available direct care staff at a sufficient level to provide active treatment and ensure 
client safety. 
 
The ICF/IID must incur the entire cost of any video camera usage in the facility.  Clients or 
their families may not be charged. 
    Spell of Illness Certifications 
 
2160 - Purpose of Certifying 1861(e)(1) and 1819(a)(1) of the Act 
Status of Hospitals and SNFs 
(Rev. 1, 05-21-04) 
 
 
2160A - Benefit Period Provision 
(Rev. 1, 05-21-04) 
 
A Medicare beneficiary is limited to a specific maximum number of days of covered 
inpatient hospital care and covered post-hospital extended care in a SNF within a period of 
time known as a spell of illness or benefit period.  Once these benefit days have been used, 
additional benefit days are not available until the spell of illness ends and a new benefit 
period begins. 
 
Section 1861(a) of the Act defines the term spell of illness and states that to end a spell 
of illness, a beneficiary must not have been an inpatient of any hospital as defined in 
1861(e)(1) of the Act or a resident of a facility described in 1819(a)(1) (formerly 
1861(j)(1)) of the Act for 60 consecutive days. 
 
NOTE:  Section 1819(a)(1) of the Acts basic definition of a SNF for spell of illness 
purposes was formerly contained in 1861(j)(1) of the Act.  Thus, a reference to 
1861(j)(1) of the Act in older material should be read as a reference to 1819(a) of the 
Act. 
 
Therefore, to enable beneficiaries, providers, and intermediaries to ascertain eligibility for 
additional benefits, classify institutions to which a beneficiary may have been removed on 
the basis of whether the institutions meet the 1861(e)(1) or 1819(a) definitions. 
 
2160B - Defining Medicare Eligible Individuals Home for Purposes of 
Durable Medical Equipment (DME) and Home Health Benefits 
(Rev. 1, 05-21-04) 
 
Sections 1861(s)(6) and 1861(n) of the Act provide that purchase or rental of DME such 
as iron lungs, oxygen tents, hospital beds, or wheelchairs may be covered under Part B of 
the Medicare program if used in the patients home.  Similarly, home health benefits can 
be paid for certain services that are furnished in a patients home.  An institution that 
meets the requirements of 1861(e)(1) or 1819(a)(1) of the Act cannot be considered a 
patients home for purposes of this benefit.  If a facility is certified as a hospital, a 
Medicare SNF, or any other facility that meets the requirements of 1861(e)(1) or 
1819(a)(1) of the Act, it is not considered the patients home.  Therefore, the institutions 
1861(e)(1) or 1819(a)(1) status is used for these purposes also. 
 
2160C - Defining Institution for Ambulance Benefit 
(Rev. 1, 05-21-04)   
Another use of 1861(e)(1) or 1819(a)(1) of the Acts definitions is to help determine 
whether ambulance benefits can be paid.  The benefit requires that transportation be to or 
from an institution (i.e., other than the patients home). 
 
2162 - Defining Hospital for Spell of Illness, DME, and Home Health 
Benefit Purposes 
(Rev. 1, 05-21-04) 
 
The term hospital as used in 1861(e) of the Act and State licensure laws has a 
generally accepted meaning that is seldom questioned. A problem arises, however, with 
respect to distinct parts of hospitals that render types of care other than hospital care (e.g., 
LTC).  For example, a hospital may have separate wings or buildings for services ranging 
from residential to skilled nursing services.  The SA evaluates these non-hospital parts in 
terms of whether they meet the definition of hospital in 1861(e)(1) of the Act.  The SA 
also states whether these parts meet the definition of skilled nursing facility in 
1819(a)(1) of the Act. 
 
Although a psychiatric hospital is precluded from participating in the Medicare program 
as a SNF, the spell of illness test is applied to such institution, and any non-hospital 
portions must be certified for spell of illness purposes. 
 
2164 - When to Make Spell of Illness Certification 
(Rev. 1, 05-21-04) 
 
It is not necessary that the SA makes 1861(e)(1) or 1819(a)(1) determinations for 
Medicare-certified hospitals or Medicare-certified SNFs. Section 1861(e)(1) of the Act 
contains a basic definition that all hospitals meet.  Similarly, 1819(a)(1) of the Act 
contains the statutory definition of a SNF, which is the basis for Medicare certification 
requirements of SNFs in 42 CFR 483, Subpart B. 
 
In many States, licensing laws for all nursing homes have incorporated the requirements 
of 1819(a) or 1919(a) of the Act or the criteria contained in 2166.  When this is the 
case, any nursing home licensed in such States cannot be considered a residents home for 
purposes of spell of illness, DME, ambulance, and HHA benefits.  In other States it may 
be necessary for the SA to make 1861(e)(1) or 1819(a)(1) certifications, as appropriate, 
in the following instances: 
 
  Nonparticipating parts of newly certified Medicare distinct part SNFs; 
 
  Nonparticipating parts of Medicare SNFs that change from complete to distinct 
part certifications or that change the size or location of the participating distinct 
part;  
  Terminated, denied, or withdrawn Medicare SNFs; 
 
  New institutions offering any level of nursing care or rehabilitation which do not 
intend to participate in Medicare;    
  Changes in the 1819(a)(1) status of facilities that come to the SAs attention 
through licensure, surveys, or other means; and 
 
  Parts of hospitals providing patient care but not rendering hospital services. 
 
Routine periodic recertifications of spell of illness requirements are not required.  
 
2166 - Criteria for Certifying 1819(a)(1) of the Act Status of LTC 
Facilities Other Than SNFs  
(Rev. 1, 05-21-04) 
 
As indicated above, SNFs meet 1819(a)(1) requirements, as do LTC facilities in States 
where licensure laws require it.  In other situations, a facility or a part of a facility meets 
the standard set forth in 1819(a)(1) of the Act for purposes of determining spell of illness 
status if it meets each of the following: (See Exhibit 10, Form CMS-1539A, Certification 
and Transmittal for Spell of Illness Determination.) 
 
2166A - Nursing Services 
(Rev. 1, 05-21-04) 
 
Nursing services are provided under the direction or supervision of one or more RNs or 
licensed practical or vocational nurses without regard to whether the facility has the nurse 
staffing requirement waived.  The SA considers this condition met even if the nurse is 
also the administrator of the facility or is employed on a part-time basis. 
 
2166B - 24-Hour Nursing Services 
(Rev. 1, 05-21-04) 
 
Nursing personnel are on duty 24 hours a day.  The term nursing personnel includes 
RNs, licensed practical or vocational nurses without regard to whether they are waived, 
practical nurses, student nurses, nurse aides, and orderlies. 
 
2166C - Nurse-Bed Ratio 
(Rev. 1, 05-21-04) 
 
The number of full-time equivalent nursing personnel to the number of beds is not less 
than an average ratio of 1 to 15 per shift. 
 
NOTE:  Generally, there will be a close equivalency between the number of beds and the 
average number of patients in an institution.  When circumstances indicate a significant 
discrepancy in these factors, the ratio of nurses to the average patient census should be 
used in certifying 1819(a)(1) status.  
 
A facility that has three 8-hour shifts must have a minimum of the equivalent of three full-
time nursing personnel during a 24-hour period for each 15 beds.  It is not necessary that 
the 1 to 15 ratio be maintained for each shift, but the average of all shifts must be at least 1  to 15.  In determining the ratio, the SA counts nurses who are also administrators as 
nursing personnel. 
 
2166D - Other Services 
(Rev. 1, 05-21-04) 
 
Bed and board are provided to inpatients in connection with the furnishing of nursing care, 
plus one or more medically-related health services such as physicians services, physical, 
occupational or speech therapy, diagnostic and laboratory services, and administration of 
medication.  (Social, diversional, or recreational services provided by the institution are 
not considered medically-related health services.) 
 
2168 - Additional Development Required for Spell of Illness 
Certifications 
(Rev. 1, 05-21-04) 
 
Ordinarily, the SA has sufficient information available in certification, licensure, welfare, 
or other records to certify the spell of illness status of an institution under the rules and 
criteria set forth in the previous sections. 
 
If the facility assigns staff specifically to separate patient care units, the SA records 
separate data for each such unit on the appropriate survey report (i.e., page 12 of Form 
CMS-1537 for hospitals or Form CMS-671 for LTC facilities), identifying the location of 
the units or the room numbers of each unit. 
 
A.   Additional Development 
 
Where existing records are inadequate, the SA uses any reliable method (e.g., letters and 
phone calls) to obtain additional evidence to determine spell of illness status.  If any 
doubts exist, the SA visits to verify. 
 
B.   Institution Consists of Single Building 
 
If an institution consists of a single building, the SA completes separate spell of illness 
determinations for the nonparticipating part(s) of the institution. 
 
C.   Institution Consists of More than One Building 
 
If an institution consists of more than one building, the SA completes separate spell of 
illness determination for the nonparticipating parts of the institution in each building.  Home Health Agencies (HHAs) 
 
2180 - HHA  Citations and Description 
(Rev. 1, 05-21-04) 
 
2180A - Citations 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The statutory authority for applying CoPs to HHAs is found in 1861(o) and 1891 of the 
Act.  The regulations are found in 42 CFR Part 484 (484.)  Appendix B contains 
Investigative Procedures and Interpretive Guidance for surveyors. 
 
The CMS has a web site for information pertaining to HHA survey and certification, 
including links to HHA policy memos, HHA-related information in the State Operations 
Manual,  2180 - 2202.19, and Appendix B, Part I-Investigative Procedures and Part II 
Interpretive Guidelines available at:   
http://www.cms.gov/Medicare/Provider-EnrollmentandCertification 
/SurveyCertificationGenInfo/index.html?redirect=/SurveyCertificationGenInfo/ 
 
Additional information can also be found at the Home Health Agency (HHA) Center at: 
http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-
Center.html?redirect=/center/hha.asp. 
 
2180B - Types of Agencies 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
An HHA may be a public, nonprofit or proprietary agency or a subdivision of such an 
agency or organization. 
 
1.  Public agency is an agency operated by a State or local government.  Examples 
include State-operated HHAs and county hospitals.  For regulatory purposes, 
public means governmental. 
 
2.  Nonprofit agency is a private (i.e., nongovernmental) agency exempt from Federal 
income taxation under 501 of the Internal Revenue Code of 1954.  These HHAs 
are often supported, in part, by private contributions or other philanthropic sources, 
such as foundations.  Examples would include non-profit visiting nurse 
associations or non-profit hospitals.  
 
3.  Proprietary agency is a private, profit-making agency or profit-making hospital. 
 
2180C - General Requirements 
(Rev. 1, 05-21-04) 
 
Section 1861(o) of the Act defines an HHA as an agency or organization which: 
 
  Is primarily engaged in providing skilled nursing services and other therapeutic  services; 
 
  Has policies established by a group of professionals (associated with the agency or 
organization), including one or more physicians and one or more registered 
professional nurses, to govern the services which it provides; 
 
  Provides for supervision of above-mentioned services by a physician or registered 
professional nurse; 
 
  Maintains clinical records on all patients; 
 
  Is licensed pursuant to State or local law, or has approval as meeting the standards 
established for licensing by the State or locality; 
 
  Has in effect an overall plan and budget for institutional planning; 
 
  Meets the CoPs in the interest of the health and safety of individuals who are 
furnished services by the HHA; and 
 
  Meets additional requirements as the Secretary finds necessary for the effective 
and efficient operation of the program. 
 
For purposes of Part A home health services under Title XVIII, the term home health 
agency does not include any agency or organization which is primarily for the care and 
treatment of mental diseases. 
 
The CoPs for a Medicare-approved HHA found in 42 CFR Part 484 are also based on 
1891 of the Act.  These CoPs are listed in Appendix B, Interpretive Guidelines for 
HHAs.  Section 1891 of the Act requires, among other things, that the HHA:  
 
  Protect and promote the rights of each individual under its care; 
 
  Disclose ownership and management information required under the Act; 
 
  Not use as a home health aide (on a full-time, temporary, per diem, or other basis) 
any individual to provide items and services described in 1861(m) of the Act, 
unless the individual has completed a training and competency evaluation program 
(CEP) or a CEP that meets minimum standards established by the Secretary, and is 
competent to provide such items and services; 
 
  Operate and provide services in compliance with all applicable Federal, State, and 
local laws and regulations (including the requirements of 1124 of the Act); 
 
  Operate and provide services in compliance with accepted professional standards 
and principles which apply to professionals providing items and services for the 
HHA; 
    Include an individuals plan of care (PoC) required under 1861(m) of the Act as 
part of the clinical record described in 1861(o)(3) of the Act; and 
 
  Comply with the requirements of 1866(f) of the Act relating to maintaining 
written policies and procedures respecting advance directives. 
 
2180D - Services Provided 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14)  
 
All HHAs must provide skilled nursing services and at least one of the following other 
therapeutic services:  physical therapy, speech language pathology, or occupational 
therapy, medical social services, or home health aide services in a place of residence used 
as a patients home. The HHA must provide at least one of these services (i.e., skilled 
nursing, physical therapy, speech language pathology, occupational therapy, medical 
social services, or home health aide services) directly and in its entirety by employees of 
the HHA. The other therapeutic services and any additional services may be provided 
either directly or under arrangement. 
 
An HHA is considered to provide a service directly when the person providing the 
service for the HHA is an HHA employee.  For the purpose of meeting 484.14(a), an 
individual who works for the HHA on an hourly or per visit basis may be considered an 
agency employee if the HHA is required to issue a Form W-2 on his/her behalf. 
 
An HHA is considered to provide a service under arrangements when the HHA provides 
the service through contractual or affiliation arrangements with other agencies or 
organizations, or with an individual(s) who is not an HHA employee.  The HHA is 
responsible for ensuring that the applicable CoPs are met, as though the HHA was 
furnishing the services directly. 
 
When hourly or per visit contracts are used, or when services are provided under 
arrangement, there must be a written agreement or contract between such personnel, or 
this agency or organization, and the HHA which specifies: 
 
  Patients are accepted for care only by the primary HHA; 
 
  The services to be furnished under the contract or agreement; 
 
  The necessity to conform to all applicable agency policies, including personnel 
qualifications; 
 
  The responsibility for participating in development of plans of care; 
 
  The manner in which services will be controlled, coordinated, and evaluated by the 
primary HHA; 
 
  The procedures for submitting clinical and progress notes, scheduling of visits, 
periodic patient evaluation; and   
  The procedures for payment for services furnished under the agreement or 
contract. 
 
2180E  Application of Home Health Agency Conditions of Participation 
to Patients Receiving Chore Services Exclusively 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
In addition to the home health services listed in 1861(m) of the Act, and Medicaid State 
Plan services identified in 1905(a) of the Act, some HHAs choose to offer additional 
services which are clearly non-medical in nature.  Such services are typically comprised of 
housekeeping, chore, or companion services.  The HHA makes these services available to 
individuals who choose to pay for them privately, and/or individuals who are provided 
these services from other programs, such as a State Medicaid Home and Community-
Based Services (HCBS) Waiver Program under 1915(c) of the Social Security Act.  The 
HHA may offer these services to current patients of the HHA (to supplement the skilled 
services available), to previous patients who have been discharged from skilled care, and 
to other individuals in the community who request them. 
 
Many individuals who receive these non-medical services are frail, elderly or disabled and 
request these services because they are unable to perform them independently and need 
this kind of assistance to remain in the home environment. 
 
In addition to promoting the health and safety of individuals, 1891(b) of the Social 
Security Act also directs the Secretary to ensure that requirements promote the effective 
and efficient use of public moneys.  This statutory direction is especially pertinent in the 
question of whether expenses ought always to be incurred for a comprehensive assessment 
and care plan when the only service requested from an HHA by an individual is a chore or 
other clearly non-medical service.  When this is the case, we will not consider the 
individual to be a patient of the HHA in the traditional sense of the term, and requirements 
that must apply to patients will not be required in such limited situations (e.g., the 
requirement for a comprehensive assessment under 484.55 will not apply). 
 
The Medicare HHA CoPs do not apply to those individuals who receive only chore 
services or other clearly non-medical services from the HHA.  Non-medical services 
include chore services, companion services, household maintenance and repair services, 
lawn and tree services, and clearing walkways.  To the extent that there is ambiguity as to 
whether a service is non-medical or medical, we will incline towards the medical 
interpretation and consider the CoPs to apply. 
 
CMS considers as a medical service any hands-on service, personal care service, cueing, 
or activity that is in any way involved in monitoring the patients health condition. As 
soon as the HHA provides any Medicare service to an individual, or any standard service 
permitted by Federal law under the Medicaid State Plan (such as personal care), we will 
consider the individual to be receiving medical care. The CoPs will apply for all services 
rendered to such an individual.  For example, the CoPs would apply in the case of an 
individual who received both chore services and personal care (regardless of funding  source), but would not apply in the case of an individual receiving only chore services 
from the HHA. 
 
HHAs are required as a part of the patient rights CoP to advise the patient of the extent to 
which payment for HHA services may be expected from Medicare or other sources and 
the extent to which payment may be required from the patient.  The HHA should explain 
to a beneficiary who is ending a Medicare episode and continuing to receive chore 
services that Medicare does not pay for those services. 
 
HHAs may develop their own comprehensive assessment for each required time point 
under the regulations at 484.55 for those patients receiving personal care services only 
regardless of payer source.  The assessment may be performed any time up to and 
including the 60th day from the most recently completed assessment. 
 
The HHA must continue to meet all State licensure and State practice regulations 
governing the provision of service to this population. Where state law is more restrictive 
than Medicare, (e.g., State law or State Medicaid HCBS requires the HHA to comply with 
CoPs when providing only chore services) the provider needs to apply the State law 
standard as well. 
 
Note that this instruction does not supersede any current policy related to Medicare 
coverage and eligibility rules or instructions from the Medicare Administrative 
Contractors (MACs). The HHAs that provide non-medical services must also ensure that 
fiscal accounts are structured and maintained in conformance with CMS regulations and 
generally accepted accounting standards. 
 
2182 - Organization of HHA 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
It is permissible for an HHA to be located at a single site or have a parent site with 
services available at other approved locations, unless prohibited by State law or 
regulation.  If there is more than one site, there must be a designated parent site with any 
other designated sites (branches and/or subunits) being part of that agency as described in 
more detail below.  The parent, branch or subunit must be operational during normal 
business hours as defined by the parent or subunit. 
 
Subdivisions 
 
A subdivision is a component of a multi-function health agency, such as a hospital-based 
HHA or the nursing division of a health department, which independently meets the CoPs 
for HHAs.  A subdivision would need to meet all requirements for the initial survey 
including completing the CMS Form-855A and having this form verified by the assigned 
MAC.  A subdivision may have subunits and/or branch offices and, if so, is regarded as a 
parent agency. 
 
Parent HHA 
  The parent HHA is that part of the HHA that develops and maintains administrative 
control of all approved locations.  The parent is listed on the Medicare Enrollment 
Application (Form CMS -855A.)  The parent HHA is responsible for all services provided 
at the parent and those provided at any of its approved branch locations. The parent HHA 
must also submit any relevant updates for all approved locations on the Form CMS-855A.  
 
Branch Offices 
 
A branch office is a location or site from which an HHA provides services within a 
portion of the total geographic area served by the parent agency.  The branch office is part 
of the HHA and is located sufficiently close to the parent agency so that it shares 
administration, supervision, and services with the parent agency on a daily basis.  The 
branch office is not required to independently meet the CoPs as an HHA. When the 
surveyor is conducting a survey of an HHA with branch offices, ascertain from HHA 
records whether the branch offices are provided adequate supervision by the parent agency 
and whether they are, in fact, sufficiently close to the parent agency to be considered 
branch offices rather than subunits.  If this judgment cannot be made without direct 
observation, the surveyor should visit the branch office to make this determination.  When 
reviewing records and conducting visits to patients homes, the surveyor selects some 
records and/or schedules some home visits to patients who are served by each branch 
office.  The surveyor may also conduct a standard survey of the HHA at a branch office.  
When conducting a survey at a branch, the surveyor may request that all necessary 
documentation for review be transported to the branch.  This may include, but not be 
limited to, a sample of clinical records from the parent and any other branches, governing 
body minutes, personnel records, etc.  
 
Subunits 
 
A subunit is associated with the parent HHA but is a semi-autonomous organization that: 
 
(1) Serves patients in a geographic area different from that of the parent agency; and 
(2) Must independently meet the conditions of participation for HHAs because it is too far 
from the parent agency to share administration, supervision, and services on a daily basis. 
 
The standards on governing body, administrator, and under the circumstances noted here, 
the group of professional personnel, will be found met by subunits if they are met by the 
parent agency.  The parent agencys group of professional personnel may serve as the 
subunits group of professional personnel if that group is effectively pursuing its 
responsibilities for the HHA and its subunits.  The parent agencys and subunits records, 
i.e., policy statements and minutes of group meetings, must establish that attention is 
being paid to the subunits operation in delivering services.  The subunit may establish its 
own group, or the parent HHA may have a subcommittee of its group deal specifically 
with the subunits policies and procedures. 
 
The subunit must submit an initial enrollment application Form CMS-855A and undergo 
an onsite initial survey from the State Agency (SA) or a National Accreditation 
Organization (AO) with deeming authority, before it is approved to participate in  Medicare.  The SA completes the Form CMS-2567, or the AO completes the equivalent, 
and all other applicable documents for the parent organization and each subunit.  The SA 
or AO does not conduct the initial survey of a subunit prior to the initial survey of the 
parent agency. The CMS certification numbers (CCNs) are assigned numerically by the 
Regional Office (RO).  
 
NOTE:  Some states do not allow HHAs to operate subunits.  If an HHA resides in a state 
with this prohibition, the HHA must comply with the more stringent State requirement. 
 
2182.1 - Characteristics Differentiating Branches From Subunits of 
HHAs 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The comparisons on the following pages identify and clarify policies that assist in making 
a distinction between a branch and a subunit.  The surveyor discusses any discrepancies 
with the administrator or his/her designee and alerts the SA supervisor who then notifies 
the CMS RO. 
 
Administrative Functions (Relationship with Parent Agency) 
 
Branch - Not autonomous.  Is part of the HHA and shares administration, 
supervision and services with the parent agency on a daily basis.  The 
administration at the parent agency is aware of the staffing, patient census and any 
issues/matters affecting the operation of any given branch.  The branch location 
provides the same services as the parent within a portion of the total geographic 
area served by the parent agency. 
 
Subunit - Semi-autonomous and located at such a distance from the parent agency 
that it is incapable of sharing administration, supervision, and services on a daily 
basis.  Serves patients in a geographic area different from that of the parent.  A 
subunit may have a branch. 
 
Compliance with CoPs 
 
Branch - Does not have to independently meet the CoPs as an HHA. 
 
Subunit - Independently meets all CoPs as an HHA. 
 
Organizational Structure (See 484.14.) 
 
Branch - The lines of authority and professional and administrative control are 
clearly delineated in both organizational structure and in practice and can be traced 
to the parent agency. 
 
Subunit - The lines of authority and professional and administrative control are 
clearly delineated in both organizational structure and in practice. 
  Supervision (See 484.2.) 
 
Branch - Supervision is shared between the parent agency and the branch.  
However, if the branch is so large (i.e., has a large staff and serves many patients) 
or is so distant that it is impossible for a supervisor of a specific discipline to 
accomplish adequate supervision, the branch must convert to a subunit. 
 
Subunit  It is too far from the parent agency to share supervision on a daily basis.  
The subunit functions independently of the parent, and consequently, supervision 
is provided by staff designated by the subunit. 
 
Administrator (See 484.4.) 
 
Branch - The administrator of the HHA maintains an ongoing management of the 
branch staff and liaison with the group of professional personnel.  In order to 
accomplish this activity, sufficient time must be allocated for sharing information 
with all the parties mentioned.  The branch is located sufficiently close to the 
parent to share administration.  The administrator is apprised of and resolves issues 
affecting patients in branch(es) as well as the service area(s) covered by the parent. 
 
Subunit - It is too far from the parent agency to share administration on a daily 
basis.  Is semi-autonomous and maintains its own administrative staff (e.g., 
supervising physician or registered nurse).  It functions as an independent entity. 
 
Supervising Physician or RN (See 484.14(d).) 
 
Branch - The location of the branch, in relation to the parent, is such that the parent 
is able to assure adequate supervision during all operating hours.  (See 2182.4B) 
 
Subunit - Supervisory M.D. or RN is available during all operating hours. 
 
Personnel Policies (See 484.14(e).) 
 
Branch - The parent office maintains current personnel records on all staff.  A 
statement of personnel policies is maintained in each branch for staff usage. 
 
Subunit - Personnel policies and records must be maintained at the subunit. 
 
Coordination of Patient Services (See 484.14(g).) 
 
Branch - Information concerning care provided to patients is communicated to 
staff in branches and parent agency, particularly when staff of one organizational 
unit (e.g., branch) does not base its practice at that site.  (Example:  A physical 
therapist (PT) provides services to patients managed by the parent agency as well 
as patients managed by the branch.  Most of the PTs time is spent with patients 
from the branch, although occasionally a patient followed by the parent agency is 
included in his/her workload. The PT is expected to coordinate care with staff in  each organizational unit [i.e., branch or parent] as required by the patients needs 
and as practice dictates.) 
 
Subunit - Since the subunit is a semi-autonomous entity, coordination is simplified 
because staff is generally available on a regular basis or can easily be reached to 
discuss and implement the coordination of patient care. 
 
Services Under Arrangements (See 484.14(h).) 
 
Branch - Contracted arrangements with various entities are the responsibility of the 
parent agency, even when the contracted services are used exclusively by the 
branch. 
 
Subunit - Maintains contracts with various entities to provide services.  The 
subunit is responsible for the administration and supervision of those services.  
Parent agency monitors subunit services provided under arrangements. 
Group of Professional Personnel (See 484.16.) 
 
Branch - The annual review of the agencys policies is conducted by a group of 
professional personnel.  Their focus is directed on service delivery throughout the 
entire agency including the parent agency and branch(es). 
 
Subunit  The subunit may establish its own group of professional personnel or it 
may form a subcommittee of the parent HHAs group which deals specifically 
with the subunits policies and procedures at that subunit.  The parent agency and 
subunits policy statements and minutes of group meetings must include specific 
references to issues addressed in the delivery of home health services.   
 
Clinical Records (See 484.48.) 
 
Branch - Should retain the clinical records for its patients, since the branch site is 
where the professionals providing the services are located.  Duplicate records need 
not be maintained at the parent agency, but must be made available to the surveyor 
upon request. 
 
Subunit - Maintains clinical records on all its patients. 
 
 
2182.2 - Guidelines for Determining Parent, Branch, or Subunit 
(Rev. 1, 05-21-04) 
 
The following guidelines should be used when making a determination as to whether a 
proposed HHA unit is a parent, branch, or subunit as defined at 42 CFR Part 484.2: 
 
A.  Supervision 
 
Supervision of the branch staff is critical to the provision of quality care for patients.  The  regulations require the branch to be within the parents geographical service area and close 
enough to the parent to share supervision, administration, and services on a daily basis.  
Supervision means authoritative procedural guidance by a qualified person for the 
accomplishment of a function or activity.  Supervision at the branch must be adequate to 
support the care needs of the patients. 
 
Supervision of services requires that a qualified person be physically present to directly 
supervise the provision of services by any individual who does not meet the qualifications 
specified at 42 CFR Part 484.4.  For individuals that do meet the qualifications specified at 
42 CFR Part 484.4, the supervisor does not have to be physically present during the 
provision of all services.  The use of telephones, pagers, facsimile machines, or other 
electronic devices does not eliminate the requirement for the physical presence of the 
supervisor.  The parent may appoint an effective full time branch supervisor or manager as 
long as this individual is and remains under the supervision of the parent.   
 
B. Distance 
 
Mileage and travel times from the parent to the branch are significant factors to consider 
because they are implicitly referenced in the regulations.  However, each alone would not 
be the single issue in determining appropriateness.  The regulations require that a branch 
be sufficiently close to share administration, supervision, and services in a manner that 
makes it unnecessary for the branch to meet the CoPs on its own.  To accomplish this, the 
parent agency must be physically located so that sharing of administration, supervision, 
and services with the branch can occur on a daily basis.  If the parent is not capable of 
sharing such functions with the branch on a daily basis, then the non-parent office or 
location must independently meet the CoPs. 
 
C.  Geographic Area 
 
Geographic area generally means the location, i.e., address of the clients served by the 
parent and non-parent.  If the non-parent office is located within a portion of the total 
geographic area served by the parent, but serves patients outside the geographic area, then 
the non-parent should not be a branch and would be classified as a subunit.  (If the State 
does not recognize subunits, the HHA would seek a new provider number and establish a 
parent location.)  This is consistent with the subunit definition that applies to a non-parent 
office that serves patients in a geographic location different from the parent. 
 
D.  Sharing Administration, Supervision, and Services 
 
In addition, consider that the sharing of HHA administration, supervision, and services 
may occur at any time and could flow in either direction, i.e., parent to branch or branch to 
parent. 
 
If an entity within the HHAs organizational structure reports directly to the home or 
corporate office or some other office other than the alleged parent HHA, it is more likely a 
subunit rather than a branch.  As a subunit it would need to independently meet the CoPs. 
  If the parent HHA and the non-parent use totally different staffs, it is less likely they are 
sharing functions on a daily basis, and it is therefore less likely that a parent/branch 
relationship exists. 
 
The fact that the non-parent office is located in a different metropolitan statistical area 
(MSA) from that of the parent is a consideration in making determinations about 
geographic areas.  Commuting patterns are one consideration in the establishment of 
MSAs.  If the parent and non-parent are in different MSAs, it may reflect that the non-
parent is not within sufficient proximity to the parent to share functions on a daily basis.  
This is especially true if the parent and non-parent are in non-contiguous MSAs. 
 
If the parent and non-parent are incapable of sharing emergency functions, including 
services, on a daily basis, the non-parent is probably not a branch. 
 
State licensure laws that define parent, branch, and/or subunit are a consideration in 
making non-parent determinations, but it is the definitions in the Federal regulations 
(42 CFR Part 484.2) that must be satisfied in making parent, branch, or subunit 
determinations.  If an HHA operates across State lines, follow the instructions in 2184 of 
the State Operations Manual.  The SA in the State in which the parent is located should 
take the lead in coordinating with the adjacent State to resolve parent and non-parent 
issues. 
 
The fact that the Joint Commission on the Accreditation of Healthcare Organizations or 
the Community Health Accreditation Program has awarded branch status to a location will 
not affect CMS parent/non-parent decision.  CMS determination will be based on its 
independent application of its regulations to the facts in the case. 
 
2182.3 - Processing A Change From Branch to Subunit 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
When a determination is made that a previously approved branch should become a 
subunit, either through a request from an existing provider or through a determination by 
CMS, an initial survey and certification is required, as with any new provider.  In such a 
situation, follow the existing survey and certification rules for conducting an initial survey 
and issuing a provider agreement and CCN to the subunit.  Similarly, if a location is 
discovered that has never been identified to the SA or CMS that is subsequently 
determined to be a subunit, an onsite survey in accordance with the usual survey and 
certification rules will apply.  The subunit, as a new provider, must also meet all 
requirements for initial certification, including completing the CMS-855A and having this 
form verified by the assigned MAC.  Note that a subunit may have branches.  (See 
Medicare Program Integrity Manual, Chapter 15, Medicare Enrollment, Section 15.19.) 
 
2182.4 - CMS Approval Necessary for Non-Parent Locations 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
As part of the provider certification process, an existing Medicare-approved HHA must 
provide notification to CMS through the SA of its proposal to add a non-parent location,  i.e., branch or subunit. (See 3224.)   In the absence of notification by the HHA to add a 
branch office, CMS cannot determine whether the requirements critical to health and 
safety are met at the non-parent location.  A provider may not bill Medicare for services 
provided by either a branch or subunit where the branch or subunit is not a part of an 
approved HHA or where the branch or subunit has not been determined to meet the 
applicable CoPs. 
 
The Form CMS-855A applications are used to gather information on providers for the 
purpose establishing eligibility to furnish services to Medicare beneficiaries. 42 CFR 
424.540(a)(2) requires a provider or supplier to update its enrollment information, and 
recertify its accuracy when any changes are made.  Additionally, 424.515 requires 
revalidation of the enrollment information by providers and suppliers every 5 years and 
(every 3 years for suppliers of durable medical equipment, prosthetics, orthotics and 
suppliers) or when determined by CMS policy.  See also Chapter 10 and 15 of the Program 
Integrity Manual which can be found at: http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/pim83c10.pdf and 
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/pim83c15.pdf 
 
Before a subunit can be approved, it must seek initial certification and apply to CMS to 
receive a separate provider agreement and CCN.  These steps are outlined in Part I of 
Appendix B of the SOM under the section on Initial surveys. 
 
2182.4A - Notification by HHA to Add a Branch 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
When an HHA requests approval to add a branch location, it should contact the SA and 
provide the following information: 
 
Address and phone number of the branch; 
 
Organizational chart delineating lines of authority, professional and administrative control 
for the HHA, including the branch; 
 
Defined geographic service area (counties, cities, zip codes), and any intention to cross 
State lines (which would require a reciprocal agreement between the affected States as 
well as RO approval); 
 
Services shared with the HHA parent; 
 
Services provided directly and under arrangement; 
 
Contracts for any services provided under arrangement; 
 
Identification of any high-tech services provided (e.g., infusion therapies such as artificial 
nutrition and hydration, or chemotherapy, mechanical ventilation, tracheostomy care, 
etc.);   
Names of all branch staff and their job descriptions; 
 
Proof of branch staff qualifications (resume, licensure, aide training, etc.); 
 
Explanation of how supervision by the HHA parent will occur; 
 
Identification of the person who will resolve patient care issues at the branch;  
 
Explanation of how staff will coordinate care and services;  
 
Policies for addressing clinical and other emergency situations; 
 
Plans for addressing staff absenteeism; and 
 
State issued certificate of need, if applicable. 
 
2182.4B - SA Review of Request for Branch Determination 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The decision to approve a branch should be based on the HHAs ability to adequately 
supervise the branch and monitor all services to assure that the quality and scope of items 
and services provided to all patients promotes the highest practicable functional capacity 
for each patient so as to meet their medical, nursing, and rehabilitative needs.  
 
The SA reviews the ability of the branch location to meet the definition of a branch as 
provided in 484.2.  The regulations require the branch to be within the HHA parents 
geographical service area and sufficiently close enough to the HHA parent to share 
administration, supervision, and services on a daily basis.   
 
The SA should review the HHAs request to open a branch and consider the HHAs ability 
to comply with the following: 
 
Administration, Supervision and Services: 
 
  The HHAs governing body is responsible for the overall operations of the parent 
and branch. 
 
  The lines of authority and professional and administrative control are clearly 
delineated in the HHAs organizational structure and in practice and are traced to 
the HHA parent. 
 
  Supervision means authoritative procedural guidance by a qualified person for the 
accomplishment of a function or activity.  Supervision at the branch must be 
adequate to support the care needs of the patients.  The HHAs supervising nurse 
or physician, as required by  484.14(d), is available at all times by phone or other 
means of communication during operating hours for individuals who meet the  qualifications specified at 484.4.   Supervision of services requires that a qualified 
person be physically present to directly supervise the provision of services by any 
individual who does not meet the qualifications specified at 484.4.   The HHA 
may formally appoint a supervisor or manager who is under the direct supervision 
of the HHA parent to assist with supervision at the branch.  (The HHA parent may 
use technological means for supervision in conjunction with periodic onsite visits. 
However, the use of telephones, pagers, facsimile machines, or other technological 
or electronic devices does not eliminate the requirement for the physical presence 
of the supervisor when required.)  
 
  The group of professional personnel required by 484.16 reviews the agencys 
policies and service delivery throughout the entire agency, both parent and any 
branch(es). 
 
  The HHA parent is aware of the staffing, patient census and any issues/matters 
affecting the operation of the branch.  
 
  The HHA administrator maintains an ongoing liaison with the branch to ensure 
that staff is competent and able to provide appropriate, adequate, effective and 
efficient patient care and to ensure that any clinical and/or other emergencies are 
immediately addressed and resolved. 
 
  The HHA maintains a system of communication and integration of services 
throughout the agency, whether provided directly or under arrangement, that 
ensures the identification of patient needs, an ongoing liaison between all 
disciplines providing care, and physician availability when necessary for relevant 
medical issues. 
 
  The HHA parent has a system in place to review patient records and care at the 
branch to ensure that the branch is implementing all policies and procedures and 
complying with the CoPs for all patients. 
 
  The HHA parent monitors branch activities (clinical and administrative) and the 
management of services, as well as personnel and administrative issues.  
Depending on the organization, the administrator, quality improvement personnel, 
supervisory personnel, etc. should conduct periodic on-site visits to the branch to 
ensure the delivery of quality care. 
 
  The HHA parent provides ongoing in-service training to ensure that all staff are 
competent to provide care and services; 
 
  The HHA parent is responsible for any contracted arrangements with any 
individuals or organizations, even when the contracted services are used 
exclusively by the branch;  
 
  Services offered by the HHA parent are also offered by the branch. 
  Distance 
 
  While mileage and travel times from the parent to the branch are significant factors 
to consider because they are implicitly referenced in the regulations, each factor 
alone should not be the single issue in determining approval or denial of the 
branch.  The HHA may use current technology to meet the requirement for shared 
supervision, administration and services with the branch where onsite supervision 
is not required.  A detailed description, including examples, of the application of 
this technology must be included in the HHAs request to add a branch. 
 
  If the parent and non-parent location are incapable of sharing functions, including 
services on a daily or emergency basis, the non-parent location is probably not a 
branch. 
 
Geographic area 
 
Geographic area generally means the location, i.e., address of the clients served by the 
parent and non-parent location(s).   
 
  The branch and its service area are located within the HHA parents geographic 
service area.  If the branch is extending the current geographic service area, the 
new geographic area must be contiguous.  If the non-parent location is located 
within a portion of the total geographic area served by the parent, but serves 
patients which are located outside of and non-contiguous to that geographic area, 
then the non-parent would be classified as a subunit (not a branch) and be required 
to submit an enrollment application and to seek a separate CCN.  (If the State does 
not recognize subunits, the HHA would not be classified as a subunit and would 
seek a new CCN and become a separate HHA provider.)   
 
  The fact that the non-parent office is located in a different core based statistical 
area (CBSA) from that of the parent is a consideration in making determinations 
about geographic areas.  Commuting patterns are one consideration in the 
establishment of CBSAs.  If the parent and non-parent locations are in different 
CBSAs, it may reflect that the non-parent is not within sufficient proximity to the 
parent to share functions on a daily basis.  This is especially true if the parent and 
non-parent locations are in non-contiguous CBSAs. 
 
  If the state has a Certificate of Need requirement or other restrictions on 
geographic area or expansion of areas, the state rules apply.   
 
  If the HHA intends to operate across State lines, follow the instructions in 2184 
of the State Operations Manual.  The SA in the State in which the parent is located 
should take the lead in coordinating with the adjacent State to resolve parent and 
non-parent issues. 
 
In addition, the SA should review the HHAs past compliance history, including prior 
complaints, survey results, number of CoPs and standards out of compliance, and length  of participation in Medicare. 
 
While the HHA may notify the SA (or AO as applicable) of its proposal to establish a 
branch, and the SA or AO may make a recommendation to the CMS RO in a particular 
case, it is the CMS RO (not the SA or AO) that has the authority for approving the request 
for a Medicare approved branch. 
 
The CMS RO will review each HHAs request for a branch office on a case-by-case basis, 
and consider all the CMS guidance.  The CMS RO will communicate its final decision in 
writing to the parent HHA with a copy to the SA or AO and the HHAs Medicare 
Administrative Contractor (MAC).  The approval letter should include notification of the 
branch approval and the assigned Federal branch ID number and effective date, if 
approved.  The effective date of coverage for services provided from the branch is the date 
RO determines that the branch meets all CMS requirements. The RO should enter the 
branch ID number into the Automated Survey Processing Environment (ASPEN) prior to 
sending the approval letter to the HHA, so that the branch can begin providing services 
and collect and submit OASIS data.  Any decision to deny the request for a branch office 
should include the full range of the reasons supporting the denial and include discussion of 
the above criteria.  Use the Model Denial Letter, Exhibit 284, as appropriate and copy the 
SA. 
 
2182.4C - Onsite Monitoring of Approved Branches by the SA 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
During a survey of an HHA with approved branch offices, the surveyor will ascertain from 
HHA records whether the branch office is provided adequate supervision by the parent 
agency and whether they are, in fact, sufficiently close to the parent agency to be 
considered a branch office rather than subunit.   
 
When reviewing records and conducting visits to patients homes, the surveyor will select 
records and/or if possible, schedule home visits to patients who are served by each branch 
office.  The surveyor may conduct a standard survey of the HHA at a branch office instead 
of the parent location.  When conducting a survey at a branch location, the surveyor may 
request that all necessary documentation for review, such as a sample of clinical records 
from the parent and any other branches, governing body minutes, personnel records, etc., 
be transported to the branch.  
 
When reviewing branches during the survey process, the operations of an approved branch 
must demonstrate that: 
 
A copy of the HHAs policies and procedures is maintained in each branch.  Branch office 
personnel should be knowledgeable of the policies and consistently apply them; 
  Methods of communication between HHA parent and branch assure that all 
patients receive the necessary care and services identified through the 
comprehensive assessment and plan of care; 
 
  The branch retains the active clinical records for its patients.  Duplicate clinical  records need not be maintained at the HHA parent, but must be available to the 
surveyor upon request;  
 
  Patients are receiving appropriate care and services at the branch, and 
 
  The HHA is in compliance with OASIS submission requirements. 
 
To assist in the decision making process of determining adequate branch supervision by 
the parent and whether the branch is sufficiently close to the parent, the surveyors may 
review and utilize the HHAs branch-specific outcome based reports during the survey 
and determine if the CoPs continue to be met with the inclusion of the additional location. 
 
2182.4D - Drop Sites 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Where permitted by state and local law, an HHA may utilize a drop site for field staff 
convenience. These drop sites are not considered branches and should not meet the 
Medicare definition of a branch or operate as such.  HHAs that allow these locations to 
cross the line from drop site to branch are out of compliance with the Medicare 
requirements.  The HHA should not assign staff to these locations, accept referrals at these 
locations, advertise them as a part of the HHA, or operate them in any other way as 
branches of the HHA.  HHAs that are unsure if the location meets the definition of a 
branch may seek advice from the SA.  If the location does meet the definition of a branch, 
it must request CMS approval before providing services from this location.  The HHAs 
policies on drop sites should reflect current Federal and State requirements, including 
compliance with the Health Insurance Portability and Accountability Act of 1996 privacy 
requirements.  While these sites would not be subject to routine surveys, they may be 
subject to state or RO inspection at any time.  Any violation would be addressed by the 
SA and referred to the CMS RO for any necessary program integrity investigation and 
follow up. 
 
2182.5 - Branch Identification Numbers 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
CMS assigns an identification number to every Medicare approved HHA branch (of either 
a parent or subunit). The identification system uniquely identifies every branch of every 
HHA certified to participate in the Medicare home health program.  It also links the parent 
or subunit to the branch.  Having a system to identify branches gives CMS the capability 
of associating quality outcome results with individual HHA branches.  Also, submission 
of branch identification numbers on Outcome and Assessment Information Set (OASIS) 
assessments provides the capability of developing outcome reports that will help HHAs 
differentiate and monitor the quality of care delivered by their agencies down to the 
branch level. 
 
ROs are responsible for assigning branch identification numbers according to the ROs 
existing policies and HHAs and their respective branches are informed of their assigned 
branch identification number(s).  A sample letter is available at Exhibit 290.   HHAs will  need to enter this branch identification number on OASIS item M0016 (Branch ID).  
Detailed instructions for completion of M0016 by parent HHAs, subunits, branches, and 
HHAs and subunits without branches are included in M0016 Branch ID in Chapter 3 of 
the OASIS Guidance Manual.   
 
Each branch is numbered with the same Federally assigned CCN as the parent or subunit 
with two modifications.  There is a Q between the state code and four-digit provider 
designation plus three more digits for a 10-character branch identifier.  Branch 
identification numbers are to be used only once.  In the event that an HHA branch closes, 
its unique branch identification number is terminated and not re-used to identify another 
branch of that HHA or subunit. 
 
EXAMPLE: 
 
ABC Home Health Agency in Alabama has three branches. 
 
ABC Home Health Agency in Alabama = CCN number 017001. 
 
ABCs branches would be assigned the branch identification numbers 01Q7001001, 
01Q7001002, and 01Q7001003. 
 
Collection Of  Branch Information During Survey 
 
The Form CMS-1572, the Home Health Agency Survey and Deficiencies Report, captures 
survey and deficiency information and requests branch information at field G17 that 
includes the HHAs total number of branches and name and address of each branch 
location.  This information should be entered into ASPEN after every survey as part of the 
survey kit.  As surveys are conducted, SAs should verify that the information they have on 
branch locations is current and accurate. 
 
Branch Identification Numbers and MACs 
 
The RO notifies the MACs of the branch identification information when it is assigned.  
This communication may occur electronically or through a written letter to the provider. 
 
2183 - Separate Entities (Separate Lines of Business) 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The surveyor must be able to identify the corporate, when applicable, and organizational 
boundaries of the entity seeking certification or recertification.  The Medicare CoPs apply 
to the HHA as an entire entity and in accordance with 1861(o)(6) of the Act, are 
applicable to all individuals served by the HHA and not just to Medicare beneficiaries.  
While the purpose of the CoPs is to help ensure proper care for Medicare beneficiaries, the 
CoPs do this by defining the standards for an HHA in which Medicare beneficiaries may 
be treated, instead of establishing requirements applicable only to Medicare beneficiaries 
served by the HHA.  If however, the HHA is able to demonstrate that it operates a 
separate entity or separate line of business to which the CoPs do not apply, it must  provide the surveyor with the information to differentiate the separate line of business 
from the HHA. 
 
Neither the Act nor the Medicare regulations define a separate entity with respect to 
HHAs that Medicare approves as an HHA in accordance with the Act and the CoPs.  
When an HHA alleges that it is operating a separate line of business to which the CoPs do 
not apply, ask the HHA to produce information to enable the surveyor to differentiate 
between it and the HHA. 
 
Use the following guidelines, on a case-by-case basis, to assist in determining if a separate 
entity exists.  The following criteria should be considered in making a decision regarding a 
separate entity:  
 
  Operation of the HHA; 
 
  Consumer awareness; and 
 
  Staff awareness. 
 
2183.1 - Operation of the HHA 
(Rev. 1, 05-21-04) 
 
Ask the HHA administrator to describe the organizational, functional, and clinical 
boundaries of the Medicare-certified program in relation to any other programs the larger 
organization offers.  Other programs should be separate and distinct from the HHA.  
Ensure that the HHA has:  
 
  Separate policies and procedures for admission to the HHA, including separate 
consent forms; 
 
  Separate clinical records for all patients receiving HHA services; 
 
  Current licensure, in accordance with State requirements.  In States which license 
HHAs, review if the State has licensed separately the approved HHA and the 
separate entity, or has licensed the separate entity as another type of provider or 
supplier; 
 
  Current listing of staff employed by or contracted to the HHA; 
 
  Personnel records; 
 
  Time sheets or other records to demonstrate distinct assignment of personnel to the 
HHA; and 
 
  Separate budgets. 
 
2183.2 - Consumer Awareness  (Rev. 1, 05-21-04) 
 
The organization should differentiate the services of the HHA from other services offered 
by the larger organization.  Ask the HHA for a copy of any brochure the HHA uses to 
describe itself to the community.  Any applicable brochures should identify the HHA 
services as separate and distinct from other programs, departments, or entities operated by 
the HHA.  The HHA should be differentiated from other programs, departments or entities 
of the organization in listings, advertisements, etc.  Written material should clearly 
identify the HHA as separate and distinct from other programs, departments or entities of 
the organization. 
 
2183.3 - Staff Awareness 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The HHA staff should be knowledgeable about the HHAs policies and procedures, the 
regulatory requirements related to their role in the delivery of care in an HHA, and be able 
to identify the difference in services they provide for the HHA and other programs, 
departments, or entities of the organization. 
 
Personnel who divide time between the separate entity and the HHA must be appropriately 
trained to deliver HHA services. The HHA maintains separate time sheets for each 
individuals assigned time to the HHA. 
 
If the SA determines, based on the information provided by the HHA or for other reasons, 
that the HHA does not have a separate entity, or if the HHA or parent organization is 
unable or unwilling to provide the information, inform the HHA that: 
 
  It is in violation of the provisions of 1861(o) and 1891 of the Act which require 
compliance with the CoPs, particularly those conditions that relate to clinical 
records and disclosure of the ownership of the HHA; 
 
  It is in violation of its agreement with the Secretary under 1866 of the Act and the 
regulations related to this agreement (489.53(a)) because it has failed to provide 
information about ownership and information concerning clinical records; 
 
  It is in violation of 1128(b)(12)(A) of the Act because it has denied access to 
records to determine compliance with the CoPs, including those that relate to the 
OASIS requirements; and 
 
  It may be in violation of various requirements related to its Medicare cost reports, 
which mandate information about all of the HHAs clients in order to properly pay 
Medicare costs, and that the HHAs MAC must be notified about the allegation of 
separate entities.  (See 413.5(b)(3), 413.9, 413.13(f)(2)(ii), 413.17, 
413.50(b), 413.53(a), and 413.80(d).) 
 
The SA must report these separate entity situations to the CMS RO, along with any 
recommendations the State has concerning the operation of two distinct entities.  The State  must also indicate whether the HHA refused access to records or information that make it 
impossible for the surveyor to make a determination concerning whether the applicant or 
approved HHA complies with the HHA CoPs. 
 
The surveyor will inform the approved HHA that the SA must report the alleged separate 
entity to the CMS RO that in turn must report this information to the MAC and, if 
necessary, to the State Medicaid Director. 
 
2184 - Operation of HHAs Cross State Lines 
(Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
When an HHA provides services across State lines, whether through its own personnel, or 
a branch, or subunit, each respective SA must be aware of and approve the action.  Each 
SA must verify that applicable State licensure, personnel licensure, and other requirements 
are met in its respective State.  Any branch or subunit of the HHA must meet applicable 
State and local laws in the State that it is serving. 
 
The provision of services across State lines is appropriate in most circumstances.  Areas in 
which community services, such as hospitals, public transportation, and personnel services 
are shared on both sides of State boundaries are most likely to generate an extension of 
HHA services. 
 
When an HHA provides services across State lines, it must be certified by the State in 
which its CCN is based, and its personnel must be qualified in all States in which they 
provide services.  The appropriate SA completes the certification activities.  The involved 
States must have a written reciprocal agreement permitting the HHA to provide services in 
this manner.  The reciprocal agreement must indicate that both States are aware of their 
respective responsibilities for assessing the HHAs compliance with the CoPs within their 
State.  The agreement should assure that home visits are conducted to a sample of all 
patients, in all States served by the HHA.   
 
The CMS RO will review the required reciprocal agreement between the States to assure 
that the SA in which the branch resides is assuming responsibility for any necessary 
surveys of the branch.  If the SAs involved are unable to come to an acceptable 
arrangement on assuring the necessary surveys of the branch, even though there may be an 
existing reciprocal agreement between the States, or if the reciprocal agreement cannot 
assure the necessary surveys, the branch should not be approved.  The provision of 
interstate service without a written reciprocal agreement could severely undermine a 
States ability to fulfill its statutory responsibilities under 1864 of the Act to enforce 
Medicares health and safety requirements. It is at the discretion of the States to decide 
whether entering into reciprocal agreements is in the best interest of their residents, 
provider markets, and quality assurance and oversight systems.  
 
Exhibit 289 contains a model reciprocal agreement document that States may use to assist 
them in fulfilling their statutory responsibilities under 1864 of the Act to enforce 
Medicares health and safety requirements when an HHA provides services across State 
lines.  In those States that have a reciprocal agreement, providers are not required to be  separately approved in each State; consequently they would not have to obtain a separate 
Medicare provider agreement/number in each State.  Providers residing in a State that 
does not have a written reciprocal survey agreement with a contiguous State are precluded 
from providing services across State lines. 
 
If a State does not have a written reciprocal agreement with other States, the HHA must 
establish a separate parent agency or subunit in the State in which it wishes to provide 
services.   
 
In the event that an HHA operates in two CMS ROs, the RO responsible for the State in 
which the HHA provider agreement and CCN is based should take the lead in assuring 
that the required survey and certification activities are met. 
 
A CMS approved branch office may be physically located in a neighboring State if the 
SAs responsible for certification in each State approve the operation. 
 
Subunits of an HHA may be physically located in more than one State.  A separate 
certification is made by the SA where each subunit is located. 
 
While the HHA may notify the SA of its proposal to provide services on an interstate 
basis, and the SA may make a recommendation to the CMS RO in a particular case, it is 
the CMS RO that has the Medicare approval authority of the parent HHA and assumes 
final responsibility for approval of the operation across State lines. 
 
2185  HHA Change of Address 
(Rev. 146, Issued: 09-04-15, Effective: 09-04-15, Implementation: 09-04-15) 
 
It is inherent in the provider certification process that a provider notifies CMS of its intent 
to change the location or site from which it provides services.  Absent such notification, 
CMS has no way of carrying out its statutorily mandated obligation of determining 
whether the provider is complying with applicable participation requirements at the new 
site or location.  It is longstanding CMS policy that there is no basis for a provider to bill 
Medicare for services provided from a site or location that has not been determined to 
meet applicable requirements of participation.  This guidance is contained in 3224.   
 
When an existing HHA intends to move from its surveyed and certified location to a new 
site or location that is within the current approved geographic area, it notifies its MAC 
within 90 days of the move, and submits all required documentation including an amended 
Form CMS -855A. The RHHI reviews the form and makes a recommendation to the RO.  
The RO then makes the final decision to approve the change of location.  The 
provider notifies CMS either directly or through the SA, and, if it is a provider deemed to 
meet the requirements, it notifies its AO, in writing of the change of location. 
 
Upon receipt of the MACs approval notice, the RO will carefully evaluate the 
information, together with any supporting documentation from the provider and any other 
relevant information known to the RO in making its decision.  If a decision can be made 
on the written application and supporting documentation, CMS may grant or deny an  approval without requiring an onsite survey.  See 2702B regarding when a resurvey is 
necessary based on change of a providers size or location.   
 
CMS generally will not approve a change of location of an HHA with one or more 
previously approved branches if the new location increases the distance between the 
parent HHA and its previously approved branch(es) to a point that prevents the HHA from 
exerting the supervision and control necessary to assure the provision of quality care for 
the patients served by the branch.  If the location change is not approved, the provider may 
consider applying for a new provider number at the new location.  CMS will consider the 
information contained in section 2182.4B in its assessment of the parents ability to 
supervise the branch before approving or denying the request. 
 
2185.1  Move after Certification Survey and Before Final Medicare 
Approval 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Requests for initial certification cannot be processed to completion if a prospective 
provider moves to a new location after it has been surveyed but before the entity receives a 
determination from the RO to participate in Medicare.  If a prospective provider moves 
from its reported location after that location has been surveyed and/or accredited but prior 
to signing a provider agreement with CMS, the prospective providers application for 
initial certification becomes incomplete.  Absent a survey of the new location to which the 
prospective provider has moved, CMS is unable to determine whether applicable program 
requirements are met at the new location, and therefore is prevented from completing its 
review of the pending application.  In these circumstances, CMS advises the prospective 
provider that its application is incomplete and is denied. 
 
2186 - Health Facility-Based HHAs 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
An HHA based to a hospital, SNF, hospice, or rehabilitation facility is expected to be an 
integral but subordinate part of the institution.  Administrative and fiscal controls may be 
exercised over the HHA.  However, the HHAs policies, personnel files, and clinical 
records must be separate and identifiable.  Time records must be maintained for all 
personnel who provide home health services and must be identifiable as home health 
regardless of whether they are part-time or full-time.  The HHAs use of personnel who 
are also concurrently employed by a hospital, SNF, hospice, or rehabilitation facility is 
acceptable provided the HHAs operating hours are definite and not arbitrarily subject to 
the operation of the other institution, and provided the other institutions operation does 
not interfere with the HHAs maintaining compliance with the CoPs. 
 
An HHAs services must be supervised by an employee of the HHA.  If members of the 
institutions governing body serve the HHA as the group of professional personnel, 
minutes must reflect meetings of this group.  Clinical records may be maintained in the 
record room or department.  However, the clinical records must contain information 
pertinent only to the delivery of home health services, and should be readily available for 
either claims review or review by the SA.   
In surveying the health facility-based HHA, the SA or AO considers the institutions 
ability to share its administrative structure and personnel in fulfilling the needs and 
requirements of the HHA on a continuing basis.  The CoPs for HHAs must be applied and 
met independently. 
 
2188 - Survey of State-Operated HHAs 
(Rev. 1, 05-21-04) 
 
The same general procedures applicable to surveying other types of HHAs apply to HHAs 
operated by a State.  However, individuals associated with the HHA in an administrative, 
supervisory, or service capacity must not be involved in the certification and consultation 
functions of the SA. 
 
2194 - Surveying Health Maintenance Organization (HMO)-Operated 
Home Health Agencies (HHAs) Providing Home Health Services 
Through Medicare Survey and Certification Process 
(Rev. 1, 05-21-04) 
 
The HMOs (Medicare+Choice) which contract with Medicare to furnish HHA services 
may provide such services either directly by the HMO or through Medicare-approved 
HHAs that have a provider agreement/number with Medicare. (See 42 CFR Part 
417.416(a) and 42 CFR Part 422.20(b)(3).)  
 
If an HMO provides home health services directly as an integral part of the HMO, the 
HHA is still required to meet the HHA CoPs, including the OASIS requirements, have a 
Medicare provider number, enter into a provider agreement with the Secretary, and meet 
other survey and certification requirements, including Office of Civil Rights and 
enrollment requirements, that an HHA approved under 42 CFR Part 484.1 would have to 
comply with. 
 
When the SA receives a request to survey an HMO-operated HHA for compliance with 
the HHA CoPs, it schedules an unannounced standard survey.  The SA conducts the 
survey, and documents its findings on Form CMS-1572.  The SA completes Form CMS-
2567, obtains a PoC when necessary, and sends this information along with a completed 
Form CMS-1539 to the CMS RO.  
 
The SA resurveys approved HMO-operated HHAs according to the survey frequency 
allowed by the Secretary and determined by the SA to assure quality care and to ascertain 
whether they continue to meet the HHA CoPs. In essence, these HHAs are surveyed and 
certified the same as any other Medicare-approved HHAs. 
 
2195  Guidelines for Determining Standard Survey Frequency 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Section 1891(c)(2)(A) of the Act states that standard surveys will occur not later than 36 
months after the previous standard survey, and that the Secretary shall establish a  frequency for surveys within this 36-month interval commensurate with the need to assure 
the delivery of quality home health services. 
 
CMS will identify HHAs to be surveyed each fiscal year according to specific criteria and 
budget allowances. This list will contain the names of HHAs that have not been surveyed 
for 24 months or longer, and that are due for survey during the coming fiscal year.  CMS 
will send this list to the State Survey Agencies each year. The annual budget criteria also 
specify the priority for complaint surveys, validation surveys and any other targeted 
surveys for the upcoming fiscal year. 
 
NOTE: The survey process guidance is now found in Part I of Appendix B. 
 
2197  Surveyor Worksheets 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The following surveyor worksheets are used during each home health survey to assist the 
surveyors determination of the agencys compliance with the home health conditions of 
participation. 
 
HHA Survey Investigation Worksheet 1  Patient Sample: 
Complete one patient sample investigation worksheet for each patient record and home 
visit selected.  Use the worksheet to collect and record patient information and findings 
related to record review and home visit information to determine the appropriateness of 
care or services being furnished. Note interviews with clinicians, record 
review findings and observations. In addition to completing the worksheet, it may be 
appropriate to request the HHA to copy the most current plan of care for each patient in 
the survey sample that identifies baseline medical information for attachment to the 
patients worksheet.  Additional documentation, including assessments, medication 
profiles, visit notes, aide plans or orders may be copied to support findings.  Complete 
each section with comments related to potential tags identified or indicate Not 
Applicable/NA. 
 
HHA Survey Investigation Worksheet 2  Agency Summary: 
Use the survey investigation worksheet 2 to record a summary of any deficient practices 
identified during the survey.  Also record the type of survey(s) performed, the number of 
agency admissions in the previous 12 months as well as the number of records reviewed 
and home visits completed. 
 
HHA Survey Investigation Calendar Worksheet: 
Use the Calendar Worksheet to determine compliance with 484.18(a) and (b) and 
484.55 regarding compliance with orders for service and the findings of the 
comprehensive assessment. Services ordered can be compared to services provided to 
determine compliance with visits. 
 
2202 - Outcome and Assessment Information Set (Oasis) Requirements 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
  The home health regulations at 484.55 require that each patient receive from the HHA a 
patient-specific, comprehensive assessment.  As part of the comprehensive assessment of 
adult skilled patients, HHAs are required to use a standard core assessment data set, the 
OASIS.  See note below for information regarding collection of OASIS data on the non-
Medicare/non-Medicaid patients of an HHA.  
 
The regulations also require that OASIS data be electronically transmitted to the SA or 
CMS OASIS contractor.  These requirements are detailed at 484.20.  This regulation is 
referred to as the reporting regulation. 
 
The CMS uses the data to achieve broad-based improvements in the quality of care 
furnished, through measurement of that care, as well as to maintain a home health 
prospective payment system.   
 
In addition to requiring the reporting of OASIS data, the OASIS regulations at 484.11 
require HHAs to maintain privacy of their OASIS data and not release patient identifiable 
OASIS information to the public.  Regulations concerning State survey, certification, and 
enforcement responsibilities are found at 488.68. 
 
Effective July 19, 1999, all HHAs participating in the Medicare/Medicaid program have 
been required to comply with the comprehensive assessment and OASIS reporting 
regulations. 
 
NOTE:  HHAs must comply with the comprehensive assessment regulation at 484.55 for 
all its patients.  However, until further notice, HHAs are not required to incorporate 
OASIS items into their patient-specific comprehensive assessment for the HHAs (1) non-
Medicare/non-Medicaid patients, (2) patients under the age of 18, (3) patients receiving 
maternity services, or (4) patients receiving personal care services only (regardless of 
payer source). (See additional information in section 2180E.) 
  The collection of OASIS data on the non-Medicare/non-Medicaid patients of an 
HHA was temporarily suspended on December 8, 2003, as a provision of the 
Medicare Prescription Drug, Improvement and Modernization Act of 2003.  HHAs 
must continue to comply with the aspects of the regulation at 484.55 regarding 
the comprehensive assessment of patients.  HHAs must provide each agency 
patient, regardless of payment source, with a patient-specific comprehensive 
assessment that accurately reflects the patients current health status and includes 
information that may be used to demonstrate the patients progress toward the 
achievement of desired outcomes.  The comprehensive assessment must also 
identify the patients continuing need for home care, medical, nursing, 
rehabilitative, social, and discharge planning needs. 
 
  HHAs may continue to collect OASIS data on their non-Medicare/non-Medicaid 
patients for their own use. 
 
  Surveyors must continue to examine the completeness of the comprehensive 
assessment for all patients during a survey.  However, surveyors must not 
investigate whether the HHA included the specific OASIS items in its patient- specific comprehensive assessments of non-Medicare/non-Medicaid patients, nor 
cite deficiencies based solely on this finding. 
 
  HHAs must continue to collect, encode, and transmit OASIS data for their non-
maternity Medicare and Medicaid patients that are age 18 and over and receiving 
skilled services. 
 
2202.1 - OASIS Related Definitions 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OASIS  Outcome and Assessment Information Set - Scientifically tested data items 
developed for the purpose of measuring outcomes (and patient risk factors that affect 
outcomes) for HHA patients.  These data items alone do not constitute a comprehensive 
assessment; they must be collected as part of the assessment process at various time points 
during a patients admission to an HHA. 
 
CMSnet (formerly known as Medicare Data Communications Network-MDCN) - A 
private communications network CMS purchased to ensure the security of OASIS and 
Minimum Data Set (MDS) data transmissions to the state.  This system replaces the 
previous process of direct dial-up by public telephone lines to the SA and reflects the 
latest technology available for securing the privacy of data during transmission.  In 
addition to increased security, another benefit of the CMSnet is that it is provided at no 
cost to the HHAs.  HHAs may also apply for a CMSnet user identification and password 
for each of their branches for direct transmissions from their branches. Use of the CMSnet 
allows for all data submitted to the CMS OASIS State System to be encrypted during the 
transmission process precluding any unauthorized sources from intercepting identifiable 
data.  Similarly, data reports, which are sent by the OASIS State System to the HHA 
across the CMSnet, are also automatically encrypted and decoded.  This network 
encryption occurs automatically when the HHA uses the CMSnet and requires no special 
action on the part of the HHA other than using browser software that supports industry 
standard encryption. 
 
Comprehensive Assessment - An assessment of a patients condition that accurately and 
completely reflects the patients current health status at the time of the evaluation.  This 
assessment must identify the patients continuing need for home care and must meet the 
patients medical, nursing, rehabilitative, social, and discharge planning needs.  An HHA 
must include the collection of specific OASIS data items at specific time points during a 
patients admission as part of its comprehensive assessment process for all adult Medicare 
and Medicaid patients receiving skilled care unrelated to pregnancy or delivery.  The 
specific OASIS items associated with each assessment time point are summarized in each 
version of the OASIS data set.   The required OASIS data set and its time point related 
versions include (1) Start of Care (SOC)/Resumption of Care (ROC), (2) Follow-up, (3) 
Transfer, and (4) Discharge.  HHAs must use the most current version of the OASIS.  The 
most current version of OASIS is available on the OASIS Web site.   
 
Encode - To enter OASIS data into a computer using the Home Assessment and 
Validation Entry (HAVEN) software (provided by CMS) or other HAVEN-like software  (developed by private vendors).  HAVEN-like software must meet CMS data and edit 
specification requirements. 
 
Encryption - A system to translate plain text into scrambled code.  Encryption offers a 
higher level of security when electronically transmitting information.  The sender locks 
the data before transmitting.  The receiver unlocks the data upon receipt. 
 
HAVEN  Home Assessment and Validation Entry - A software program provided by 
CMS, free of charge, for use by HHAs to encode their OASIS data and save as electronic 
files for electronic transmission to the SA.  The HAVEN software automatically applies 
date range and consistency checks according to CMS published data specifications, 
which serve as an electronic safety net to preclude the transmission of erroneous or 
inconsistent information. 
 
Header Record - Contains basic information that identifies the HHA submitting OASIS 
data, as well as, contact persons and telephone numbers to be used in the event the file is 
in error. 
 
Initial Assessment - The HHAs first visit to the patient after referral.  In the absence of a 
specified start of care date, the initial visit is the first visit made to the patient within 48 
hours of the referral.  If the physician specifies a particular start of care date, then the 
initial visit is the date specified by the physician and includes performance of the skilled 
care ordered.  In accordance with the regulations, the initial visit must be made by a 
registered nurse except for therapy-only cases, in which the initial assessment visit can be 
made by a qualified therapist. 
 
Incorporate/Integrate - Incorporating/integrating the OASIS data items into an agencys 
assessment process means replacing similar questions on the agencys existing assessment 
tool with the corresponding OASIS data items.  Agencies must merge the OASIS data 
items into their existing assessment process rather than simply appending them without 
considering which OASIS items could replace similar items on the agencys assessment 
tool.  Simply appending the OASIS items adds time to the assessment process and renders 
it burdensome and duplicative.   Since the OASIS items are not intended to constitute a 
complete comprehensive assessment, agencies should gather other pertinent assessment 
information not included in the OASIS data items in order to create a comprehensive 
assessment.  Except as required to meet other Federal, State, or accreditation standards, 
agencies are at liberty to determine what other information they require as part of the 
comprehensive assessment. 
 
Late Assessment - An assessment transmitted after the specific time frames defined in the 
regulations. 42 CFR 484.20(a) requires the HHA to transmit the assessment within 30 
days of completing the assessment. 
 
Masking - A term used to describe software that conceals individually identifiable data 
elements.  When required, HHAs will mask these data elements prior to transmission and 
keep the masked identifiers and the original data in their records.  Private Pay assessments 
are no longer accepted by the State System.  If M0150 items 1, 2, 3 and 4 are all equal to  0 unchecked, the state system rejects the record.  Any private pay assessment entered 
into HAVEN will be marked as Complete and is excluded from the export process in 
HAVEN. 
 
Outcome - Changes in a patients health status between two or more time points. 
 
Outcome-Based Quality Improvement (OBQI) - Performance improvement based on 
outcome measurement and reporting. 
 
Outcome-Based Quality Monitoring (OBQM) Reports - The OBQM reports include 
the agency patient-related characteristics report and potentially avoidable events outcome 
reports. 
 
Overdue OASIS - OASIS assessments not received by the OASIS System within the 
specific time frames defined by the regulations. (See also Late Assessment.) 
 
Process Based Quality Improvement (PBQI) - Evaluating or investigating the use of 
specific best care processes (such as conducting falls risk assessments or providing drug 
education) by reviewing the care provided to determine any needed changes in care 
delivery. 
Quality Improvement and Evaluation System (QIES) - An online system that supports 
the CMS mission and initiatives to improve the quality of care for Medicare beneficiaries 
(Providers: Skilled Nursing Home, Home Health Agencies, as well as State Survey 
Agencies). (Includes CASPER, MDS, OASIS, RAVEN, HAVEN, and ASPEN). 
Reason For Assessment (RFA) - Reason for conducting the assessment, e.g., Start of 
Care (SOC), Resumption of Care (ROC), and Follow-Up found in M0100. 
Resumption of Care (ROC)  The day that care resumes after an inpatient stay.  The 
HHA must complete an OASIS assessment and obtain the necessary physician change 
orders reflecting the change in the treatment approach in the patients plan of care.  The 
ROC is to be done within 48 hours of the patients return home.  If the physicians order 
requests that the HHA resume care at a point later than 48 hours or if the patient refuses a 
visit within this 48-hour period, a note to this effect should be documented in the patients 
chart for future reference. 
 
Significant Change in Condition (SCIC) - A SCIC is defined as a significant change in 
the patients condition during a 60-day episode that was not envisioned in the original plan 
of care.  While this no longer creates a new case-mix for payment, the HHA must 
complete an OASIS assessment and obtain the necessary physician change orders 
reflecting the significant change in the treatment approach in the patients plan of care.  
The SCIC relates to the OASIS data set other Follow-Up (RFA5).  
 
Start of Care (SOC)  The day care begins after the referral is received.  SOC currently 
relates to the first billable visit. The first billable visit approach was selected largely 
because of the Medicare payment requirements and the fact that the first billable visit  defines SOC and start of the episode for Medicare purposes. 
 
Time Points - Specific times during an episode of care when collection of OASIS data 
items is required as part of a comprehensive assessment.  They are start of care, 
resumption of care, recertification, follow-up, and transfer to an inpatient facility, death at 
home, and discharge from agency. 
 
Trailer Record - Indicates the end of the submission file.  The trailer record includes a 
count of the total records in the file, including the header and trailer records. 
 
2202.2 - History of OASIS 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OASIS is a group of data items developed, tested, and refined over the past decade for 
the purpose of enabling the systematic measurement of HHA patient care outcomes.  
Initially, the OASIS was a 79-item data set first published in 1994 by the Center for 
Health Services and Policy Research at the University of Colorado.  Over the years, it has 
been modified as a result of input from a variety of home care experts, including 
representatives of all home health care disciplines.  Future modifications to the OASIS are 
expected as we learn more about outcome measurement as well as determine what 
information would best serve the continued maintenance of a case-mix adjusted home 
health PPS. 
 
Relative to OASIS, the definition of outcomes is very specific: outcomes measure changes 
in a patients health status between two or more time points.  The data are collected at 
specific time points following a patients admission to an HHA to determine whether 
appropriate progress toward desired outcomes is being achieved.  These data items must 
be incorporated into the agencys overall patient assessment process as OASIS was not 
developed to be a complete comprehensive assessment instrument.  HHAs will find it 
necessary to integrate the OASIS items into their own process in order to comprehensively 
assess the health status and care needs of their own patient population.  Effective, January 
1, 2010, the OASIS data set was significantly modified to include process measures. Some 
points to remember about the uses of OASIS data items into an HHAs assessment process 
can be found in Appendix C of the OASIS-C Guidance Manual. 
 
2202.2A - Current Version of OASIS 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The current version of OASIS and the Guidance manual is found on the CMS Web site at:  
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html. 
 
2202.2B - OASIS as Part of the HHAs Comprehensive Assessment 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OASIS data items are not meant to be the only items included in an agencys assessment 
process for Medicare and Medicaid patients.  They are standardized assessment items that  must be incorporated into an agencys own existing assessment policies process.  An 
example of a comprehensive assessment showing an integration of the OASIS data items 
with other agency assessment items can be found in Appendix C: Sample Clinical Records 
Incorporating OASIS Data Set, in the OASIS Users Manual.  For a therapy-only case, the 
comprehensive assessment should include OASIS data items as well as other assessment 
data items the agency currently collects for therapy-only cases. 
 
2202.2C - Incorporation of OASIS Data Items Into the Comprehensive Assessment (Refer 
to 484.55(e)) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
In accordance with the regulations, agencies MUST incorporate the language of OASIS 
data items exactly as they are written into their own assessment process.  Agencies are 
expected to replace similar items/questions on their current assessment as opposed to 
simply adding the OASIS items at the end of their existing assessment tool.  For agencies 
electronically collecting assessment data using software that does not accommodate 
bolding or underlining for emphasis of words in the same manner as the current OASIS 
data set, capitalizing these words is acceptable.  It is also recommended that HHAs 
include the data set numbers (M numbers) when incorporating the OASIS.  In this way, 
the clinician will know that the M labeled items are items that MUST be assessed, 
completed, and reported.  This will minimize delays in encoding due to incomplete OASIS 
data items.  Agencies may wish to incorporate the assessment categories (e.g., Activities 
of Daily Living (ADLs)/Instrumental Activities of Daily Living (IADLs), Medications, 
etc.) into their own assessment process in a different order than presented on the OASIS 
form.  While HHAs are encouraged to integrate the OASIS data items into their own 
assessment instrument in the sequence presented on the OASIS form for efficiency in data 
entry, they are not precluded from doing so in a sequence other than that presented on the 
OASIS form.  However, this is not recommended because of the skip patterns built into 
the OASIS form. 
 
2202.3 - Applicability 
(Rev. 1, 05-21-04) 
 
2202.3A - Medicare and Medicaid Patients 
(Rev. 1, 05-21-04) 
 
In general, the comprehensive assessment and reporting regulations apply to any HHA 
required to meet the Medicare CoPs for any reason and are applied to all patients of that 
HHA unless otherwise specified.  This includes Medicare, Medicaid, Medicare and 
Medicaid Managed Care, and private pay patients served by the agency.  It also includes 
Medicaid waiver and State plan patients to the extent they do not fall into one of the 
exception categories listed below, and are required by the State to meet Medicare CoPs.  
HHAs providing services under Medicaids home health benefit must meet the CoPs for 
Medicare, as specified at 42 CFR 440.70(d).  As such, HHAs servicing only Medicaid 
patients (Medicaid-only HHAs) must meet Medicare CoPs, including the comprehensive 
assessment and OASIS reporting requirements.  
  Health maintenance organizations serving Medicare/Medicaid patients can either provide 
home health services themselves or can contract out for those services.  If they provide 
home health services themselves, they must meet the Medicare home health CoPs.  If they 
contract out for home health services, they must contract with a Medicare-approved HHA 
in order to serve Medicare/Medicaid patients.  (See 42 CFR 417.416 and 2194.) 
 
The HHAs requirement to conduct comprehensive assessments that include OASIS data 
items applies to each patient of the agency receiving home health services with certain 
exceptions: 
 
  Patients under the age of 18;  
 
  Patients receiving maternity services;  
 
  Patients receiving housekeeping or chore services only; and 
 
  Patients receiving personal care services only. 
 
  Patients for whom Medicare or Medicaid insurance is not billed. 
 
The comprehensive assessment and reporting regulations to patients receiving personal 
care only services, regardless of payor source is not applicable. 
 
2202.3B - OASIS and the Medicare Home Health Benefit 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The comprehensive assessment and OASIS data collection requirements apply to 
Medicare beneficiaries as described below: 
 
  Medicare beneficiaries, using the Medicare home health benefit provided under 
either Part A, Part B, or Part C;  
 
  Medicare beneficiaries who require therapy services provided outside the home for 
special equipment needs, and who are using the Medicare home health benefit.  
 
If a Medicare beneficiary is under a home health plan of care, all therapy services, that is 
physical therapy, occupational therapy, speech language pathology (PT, OT, SLP), 
delivered under the home health benefit whether they are furnished directly by the HHA 
or under arrangement on behalf of the HHA are bundled into the PPS payment rate as part 
of the consolidated billing requirements. 
 
The consolidated billing governs Medicare home health PPS effective October 1, 2000 
and requires that payment for home health services (including medical supplies described 
in 1861(m)(5) of the Act, but excluding DME to the extent provided for in 1861(m)(5)) 
furnished to an individual who (at the time the item or service was furnished) is under a 
plan of care of a HHA, be made to the agency (without regard to whether or not the item 
or service was furnished by the agency, by others under arrangement with them made by  the agency, or under any other contracting or consulting arrangement, or otherwise).  The 
services included in the consolidated billing governing home health PPS are: 
 
  Part-time or intermittent skilled nursing services; 
 
  Part-time or intermittent home health aide services; 
 
  Physical therapy;  
 
  Speech-language pathology services;  
 
  Occupational therapy; 
 
  Medical social services; 
 
  Routine and non-routine medical supplies; 
 
  Covered osteoporosis drug as defined in 1861(kk) of the Act, but excluding other 
drugs and biologicals; and 
 
  Home health services defined in 1861(m) provided under arrangement at 
hospitals, SNFs or rehabilitation centers when they involve equipment too 
cumbersome to bring to the home or are furnished while the patient is at the 
facility to receive such services. 
 
If a Medicare beneficiary under a home health plan of care is receiving therapy services 
from another provider (either an inpatient or outpatient provider) under arrangement made 
by the HHA as part of the home health benefit simply because the required equipment 
cannot be made available at the patients home, the Medicare CoPs apply, including the 
comprehensive assessment and collection and reporting of OASIS data by the HHA. 
 
1.  Medicare Advantage Plans. 
 
Medicare Advantage Plans are health plan options that are part of the Medicare program. 
Medicare beneficiaries who elect to have Medicare services provided by a Medicare 
Advantage Plan are entitled to all the Medicare-covered services that are available to 
beneficiaries residing in the plans geographic area. 
 
Medicare Advantage Plans, like a Medicare Health Maintenance Organization (HMO) or 
Preferred Provider Organization (PPO), which contract with Medicare to furnish HHA 
services may provide such services either directly by the Plan or through Medicare-
approved HHAs that have a provider agreement and CCN with Medicare. (See 
417.416(a)).   If the Medicare Advantage Plan provides home health services directly as 
an integral part of the Plan, the HHA is still required to meet the HHA CoPs, including the 
OASIS requirements, have a Medicare CCN, enter into a provider agreement with the 
Secretary, and meet other survey and certification requirements, including Office of Civil 
Rights and enrollment requirements, with which an HHA certified under 484.1 would  have to comply. 
 
When the SA receives a request to survey an HMO-operated HHA for compliance with 
the HHA CoPs, it schedules an unannounced standard survey.  The SA conducts the 
survey, completes the Form CMS-2567, obtains a PoC when necessary, and sends this 
information along with a completed Form CMS-1539 to the CMS RO.  
 
The SA resurveys approved HMO-operated HHAs according to the survey frequency 
allowed by the Secretary and determined by the SA to assure quality care and to ascertain 
whether they continue to meet the HHA CoPs.  In essence, these HHAs are surveyed and 
certified the same as any other Medicare-approved HHAs. 
 
2.  Medicaid Home Health Programs/Medicaid Waiver Programs 
 
The comprehensive assessment regulations apply to HHAs that are required to meet the 
Medicare home health CoPs.  An HHA that currently must meet the Medicare CoPs under 
Federal and/or State law must meet the Medicare CoPs related to OASIS and 
comprehensive assessment and reporting.  If an HHA provides skilled services to 
individuals under Medicaid, then OASIS applies.  If the patient is not receiving skilled 
nursing, physical therapy, occupational therapy, or speech language pathology services, 
then OASIS does not apply.  The requirement to collect OASIS on patients receiving only 
personal care services has been delayed until further notice. 
 
3. Medicare Hospice Benefit 
The comprehensive assessment and OASIS data collection requirements do not apply to 
any individual receiving hospice services from a Medicare-approved hospice.  A hospice 
patient may receive covered home health services for a condition unrelated to the 
treatment of the terminal condition for which hospice care was elected.  This type of 
patient would be subject to the regulations governing the HHA services, including OASIS 
collection and reporting. 
 
4. Outpatient Therapy Benefit 
 
If a Medicare beneficiary not under a home health plan of care is receiving therapy 
services under the Medicare Part B outpatient benefit from another Medicare provider, the 
OASIS collection and reporting requirements do not apply. 
 
5. SNF or Inpatient Hospital Benefit 
 
The comprehensive assessment and OASIS data collection requirements do not apply to 
Medicare beneficiaries who are inpatients at a SNF or a hospital because these services are 
not considered home health services and the OASIS comprehensive assessment does not 
need to be conducted.  The MDS is required in certified skilled nursing facilities. 
 
The following table summarizes the type of Medicare/Medicaid service and the 
application of the Federal OASIS requirements: 
  Type of  Further Description  Application of OASIS 
Medicare/Medicaid 
Service 
Home Health Benefit  Part A  Yes 
Home Health Benefit  Part B  Yes 
Home Health Benefit  Terminal Care  Yes 
Home Health Benefit  Therapy services provided  Yes 
either directly or under 
arrangement while under a 
home health PoC during 
an open episode. 
Medicare Home Health  The selected HHA must  Yes 
under a Medicare  be Medicare approved 
Advantage plan  
Medicaid Home Health  Skilled services provided  Yes 
Benefit  including expanded home 
health services, that are 
skilled, provided under a 
Home and Community
based Waiver 
Medicaid Home Health  Waiver service or home  No 
Benefit  health aide services only 
provided without skilled 
services 
Medicare Hospice Benefit  Inpatient or at home  No 
Outpatient Therapy Benefit  Provided in a clinic,  No 
(patient not under a home  rehabilitation agency, a 
health plan of care)  public health agency or 
other provider of services 
Skilled Nursing Facility,  Inpatient services  No 
Hospital 
 
The guidance above applies to all HHAs that participate in Medicare and to HHAs that 
are required to meet the Medicare CoPs, including Medicaid HHAs. 
 
2202.3C - Non-Medicare/Non-Medicaid Patients 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The collection, encoding, and transmission requirement for non-Medicare and non-
Medicaid patients receiving skilled care is temporarily suspended.  While HHAs are not 
required to collect OASIS for non-Medicare/non-Medicaid patients, HHAs may continue 
to collect OASIS data for their own use but they may not submit the data for these patients 
to the state.  The state system will reject any assessment with a M0150 value of 0 
(unchecked) for items 1, 2, 3 and 4.  Also, HAVEN will not include these assessments in  the submission file, but will mark them as complete. 
 
2202.3D - Skilled Versus Nonskilled Care 
(Rev. 1, 05-21-04) 
 
Until the comprehensive assessment and reporting requirement resumes for all patients, 
regardless of type of care provided, the following definitions apply for determining 
skilled versus non-skilled care for comprehensive assessment purposes only: 
 
  Skilled Services for Medicare Patients - The provision of skilled service is a pre-
condition for Medicare payment for home health care.  Therefore, all patients 
receiving Medicare (traditional) home health services are, by definition, receiving 
skilled care. 
 
  Skilled Services for Non-Medicare Patients - For comprehensive assessment 
purposes, skilled services are services which can only be provided by a registered 
nurse (RN) (or a licensed practical nurse under the supervision of an RN), a 
physical therapist (PT), occupational therapist (OT), or a speech language 
pathologist (SLP), licensed by the State.  Most States define the kind of care that is 
allowed by these practitioners under State practice acts.  
 
The former requirement to conduct an initial evaluation of a patient is expanded in the 
comprehensive assessment regulations.  The regulations now require that, in addition to an 
initial evaluation, the agency must also conduct a comprehensive assessment of a patient 
with updates at certain time points.  These updates include different combinations of 
OASIS data items.  An agency that currently must meet the Medicare CoPs under Federal 
and/or State law will need to meet the comprehensive assessment and OASIS encoding 
and reporting CoPs and apply them to each patient of the agency for whom home health 
services are rendered, with the exceptions listed in A. above.  
 
2202.3E - Agencies Serving Medicaid Waiver and State Plan Patients 
(Rev. 1, 05-21-04) 
 
If home care is provided by an entity required to meet the Medicare CoPs for any reason, 
then the entity must apply all the requirements of the CoPs, including the comprehensive 
assessment and OASIS data reporting requirements, to all patients of the agency, 
including patients treated under a Medicaid waiver or State plan, as applicable.   The same 
exceptions apply as listed in A. above, i.e., patients under the age of 18; patients receiving 
maternity services; patients receiving housekeeping or chore services only; and until 
sometime in the future, patients receiving personal care services only. 
 
If home care is provided by an entity that is not required to meet the Medicare CoPs, then 
the provider must comply with only those requirements imposed under State or local law.  
In this case if the provider treats patients under a Medicaid waiver or State plan, then none 
of the Medicare CoPs for HHAs, including the comprehensive assessment and OASIS 
data reporting requirements, apply.  See 2183 for information on separate entities. 
  2202.3F - Patients Turning 18 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
A patient who is under age 18 and turns 18 while under the care of an HHA is to receive a 
comprehensive assessment (including OASIS, if Medicare or Medicaid is billed) at the 
next appropriate time point.  Any assessments due under the regulations at the time the 
patient turns 18 would be conducted, including the collection and reporting of OASIS 
data, if Medicare or Medicaid is billed. 
 
EXAMPLE 
 
If on 1/5/2013 a patient under the care of the agency turns 18 and is transferred to an 
inpatient facility on or after 1/5/2013, a transfer assessment with the corresponding OASIS 
data items must be collected.  If the patient was discharged on his/her 18th birthday, a 
discharge assessment with the corresponding OASIS data items must be collected. 
 
From the day the patient turns 18, any assessment required per the regulations at the next 
particular time point is required.  Agencies are not expected to collect and report start of 
care OASIS data on patients admitted to the agency prior to turning 18. 
 
2202.3G - Patients Receiving Maternity Services 
(Rev. 1, 05-21-04) 
 
The HHA should not collect data on patients receiving maternity services, i.e., prenatal, 
antepartum, and postpartum.  The patient is not exempt from OASIS data collection if 
under the care of a physician for a condition unrelated to pregnancy or delivery. 
 
2202.4 - Comprehensive Assessment and OASIS Reporting (Refer to 
484.20 and 484.55) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
All HHAs participating in the Medicare/Medicaid program are required to comply with 
the comprehensive assessment and OASIS reporting regulations as summarized in the 
following chart. 
 
       
PATIENT CLASSIFICATION  COLLECT  ENCODE   TRANSMIT  
       
SKILLED       
Medicare (traditional fee-for service)  Yes  Yes  Yes 
Medicare (HMO/Managed Care) 
Medicaid (traditional fee-for-service) 
Medicaid (HMO/Managed Care) 
       
SKILLED       
Non-Medicare/Non-Medicaid:  No  No  No         
PATIENT CLASSIFICATION  COLLECT  ENCODE   TRANSMIT  
Workers Compensation   
Title Programs  Temporarily
Other Government   Suspended  
Private insurance 
Private pay patients under a  HMO/   
PPO/Managed Care plan 
Self-pay; other; unknown  
       
PERSONAL CARE ONLY   No  No  No 
Medicaid (traditional fee-for service) 
Non-Medicaid: 
  Workers Compensation  
  Title Programs 
  Other Government  
  Private insurance  
  Private HMO/Managed Care 
  Self-pay; other; unknown 
       
Patients under age 18;   No  No  No 
Patients receiving pre and postpartum 
maternity services; Patients receiving only 
chore and housekeeping services 
 
2202.4A - Comprehensive Assessment and OASIS Collection 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The comprehensive assessment regulations require a comprehensive assessment (that 
includes certain OASIS data items) be conducted at specific time points during a patients 
admission.  Those specific times are: 
 
1.  SOC 
 
After admission to the HHA, the SOC comprehensive assessment should be completed 
in a timely manner consistent with the patients immediate needs but no later than 5 
calendar days after the SOC. 
 
2.  ROC 
 
The comprehensive assessment is completed within 48 hours of the patients return to 
the place of residence or of the HHAs knowledge of the patients return after an 
inpatient admission of 24 hours or more for any reason other than diagnostic tests.  
This applies when the patient was not discharged from the HHA during the inpatient 
admission.  If the physicians order requests that the HHA resume care at a point later 
than 48 hours or if the patient refuses a visit within this 48-hour period, a note to this  effect should be documented in the patients chart for future reference. 
 
3. Follow-Up - The comprehensive assessment that is performed at the end of the 
current 60-day period.  This assessment must be performed within the last 5 days of 
the current 60-day episode.  For example:  
 
Start of Care  Certification Period  Follow-Up Assessment Due 
     
1/15/20xx  1/15/20xx - 3/14/20xx  3/10/20xx - 3/14/20xx 
     
1/15/20xx  3/15/20xx - 5/13/20xx  5/09/20xx - 5/13/20xx 
     
1/15/20xx  5/14/20xx - 7/12/20xx  7/08/20xx - 7/12/20xx 
 
4.  Transfer to an Inpatient Facility 
 
An assessment update is performed when a patient is transferred to an inpatient facility 
for 24 hours or more for any reason except diagnostic testing, regardless of whether 
the patient is discharged from the HHA at that time.  The update must be completed 
within 48 hours of the patients transfer to the inpatient facility or within 48 hours after 
the HHA becomes aware of the transfer and includes a limited number of OASIS 
items. 
 
5.  Discharge 
 
The comprehensive assessment is performed when a patient is discharged from home 
care.  These updates must be completed within 48 hours of the discharge/death or 
within 48 hours after the HHA becomes aware of the discharge/death. 
 
2202.4B - OASIS Encoding and Locking 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
HHAs should use HAVEN or HAVEN-like software to encode or enter OASIS data into 
their computers.  HAVEN will accommodate data entry of OASIS items from all required 
time points. Regardless of the time point, OASIS data items should be encoded, and 
checked for errors using HAVEN or HAVEN-like software, and made 
export/transmission-ready. 
 
1. Availability of HAVEN 
 
The HAVEN software is available for downloading free of charge from the CMS OASIS 
and QIES Technical Support (QTSO) Web site. See 
https://www.qtso.com/havendownload.html 
 
The HAVEN help line can be reached at:  1-877-201-4721.   
 
Specific information describing how to operate the HAVEN software can be found at  https://www.qtso.com/download/haven/hhahelp32.pdf. 
 
2. Errors and Warnings in Encoding  
 
See Error Messages and Description Guide -- 
https://www.qtso.com/download/Guides/hha/errors/Errors_sec2.pdf 
HHAs may experience two types of messages at completion of data entry. 
a.  Error Message. 
If the HHA uses HAVEN for data entry, an error message may occur if a 
mandatory field is left blank.  The HHA will receive an error that the field must be 
filled in before the assessment can be marked as complete.  HHAs should correct 
their errors before an assessment may exported to the OASIS Data Management 
System.  Along with the error message is the name of the window tab where the 
error was detected. 
b.  Warning Message 
If the HHA uses HAVEN for data entry, a warning message may occur if timing 
criteria for date fields do not match OASIS data specifications.  These messages 
are informational only and do not preclude an HHAs assessment from being 
exported.  Along with the warning message is an explanation of that message and 
direction on where the discrepancy was detected. 
 
2202.4C - OASIS Reporting (Refer to 484.20) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
1.  HHA Submissions 
 
HHAs must submit their OASIS data within 30 days of the M0090 date, date 
assessment completed.  Data received outside of this time frame is considered 
overdue.  Specific information describing how HHAs are to transmit OASIS data to 
the SA is in the OASIS System Users Guide. 
 
2. Errors and Warnings in OASIS Reporting 
 
When submitting OASIS records, a fatal error message may occur if the HHAs data 
record layout does not follow OASIS data specifications.  This message should not 
occur if the HHA is using the HAVEN software to encode the OASIS items. 
 
3. SA Access 
 
In States where the non-long term care agency is in a location separate from the 
OASIS State System (where the MDS Data System resides and is not under the direct 
jurisdiction of the home health survey agency), CMS provides access to the OASIS 
State System by installing a computer work station at the home health survey agency  address to link to the OASIS State System. 
 
The CMS will provide additional support to the SA to access and operate the off-site 
server by providing appropriate software, and technical assistance from CMS and the 
CMS OASIS contractors. 
 
2202.5 - Outcome-Based Quality Improvement (OBQI) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OBQI is a systematic approach that HHAs can implement and follow in order to 
continuously improve the quality of care they provide.  OBQI manuals are available on the 
CMS Home Health Quality website.  Under OBQI, quality is measured against the 
ultimate yardstick - patient outcomes.  OBQI is fundamentally a two-stage process that 
requires the collection of OASIS data for all patients in the agency, except those excluded 
by exemption. 
 
The first stage of OBQI is outcome analysis based on the OASIS data.  The analysis is 
based on an agency-level report showing the agencys present performance regarding 
patient outcomes relative to a national measure of HHA patients.  Outcome reports are 
generated at the SA and retrieved by the HHA through the same communication process 
the HHA uses to transmit OASIS data.  Subsequent outcome reports contain comparisons 
of an agencys present patient outcomes performance relative to the preceding time period 
for the agency and relative to a national measure of HHA patients.  From these reports, 
HHAs can target areas for improvement as part of their overall quality assurance process. 
 
The second stage of OBQI is outcome enhancement, whereby the agency, using the data 
from its outcome analysis, identifies opportunities to improve care and develops plans.  
HHAs are provided with reports on a series of outcomes for their patients in the current 
year that compares its performance to the prior year and to the national reference (i.e., 
benchmarking) values. 
 
2202.5A - Using Outcome Based Quality Monitoring (OBQM) and Risk 
Adjusted OBQI Reports in the Survey Process 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OBQM reports consist of the patient-related characteristics and potentially avoidable 
event outcome reports, which are derived from the OASIS data that HHAs submit to the 
State.    The agency patient-related characteristics and potentially avoidable event reports 
can be used by HHAs for quality monitoring and improvement purposes.  The risk-
adjusted OBQI reports provide measures of patient care based on all of the OASIS data 
items.  These reports allow an HHA to proceed to outcome enhancement.  It is the 
outcome enhancement activities that allow an HHA to focus its quality (or performance) 
improvement activities on select target outcomes, to investigate the care processes that 
contributed to these outcomes, and to make agency-specific changes in clinical actions 
that will lead to improved patient outcomes.  Using these reports is a first step toward full 
implementation of the OBQI program.  As a part of the pre-survey preparation, surveyors 
should access and review the OBQM and OBQI reports before surveying an HHA.  These  reports contain valuable information that may assist surveyors in identifying areas to 
review during the survey and possibly identify individuals or types of patients to include 
in the sample selection when on site following guidance provided in the Home Health 
Survey Protocol Enhancements, effective May 1, 2003 published February 13, 2003 as 
S&C Memorandum 03-13.  The OBQM Manual, (titled Quality Monitoring Using Case-
Mix and Adverse Event Outcome Report available on the OASIS Web site), provides 
examples of possible surveyor actions related to adverse event outcomes.  The OBQI 
Manual (titled Outcome-Based Quality Improvement Implementation Manual provides 
guidance to HHAs for establishing a quality improvement program using the risk-adjusted 
OBQI reports.  This manual is also available on the OASIS Web site. 
 
1.  Agency Patient-Related Characteristics Report 
 
The agency patient-related characteristics report presents a picture, or snapshot, of an 
HHAs patients at the beginning of a care episode for the time period selected for the 
report.  The beginning of a care episode is marked by either a SOC assessment or a 
ROC assessment.  The body of the case-mix report describes the characteristics of an 
HHAs Medicare and Medicaid patients receiving skilled services compared to the rest 
of the Medicare and Medicaid patients receiving skilled home health services across 
the country during the same time period.  Surveyors should review the case-mix 
outcome report as described in the OBQM Manual and the Appendix titled 
Guidelines for Reviewing Agency Patient-Related Characteristics and Potentially 
Avoidable Event Reports.  Any significant results should be identified after 
reviewing the report, and highlights noted.  This will allow surveyors to begin to 
identify potential clinical groups of patients that can be included in the case-mix 
stratified sample for record review and home visits, as part of the onsite survey.  
 
2.  Potentially Avoidable Event Reports 
 
The Potentially Avoidable Event Report displays incidence rates for untoward events 
(or outcomes) comparing one HHAs patients to patients in the CMS OASIS National 
repository for the same time period.  
 
Potentially avoidable events serve as markers for potential problems in care because 
of their negative nature and relatively low frequency.  The Patient Listing can be used 
to investigate the care processes that contributed to these outcomes and to make 
agency-specific changes in clinical actions that will lead to improved patient 
outcomes.  As a part of the pre-survey preparation, surveyors should access and 
review the OBQM and OBQI reports before surveying an HHA.  These reports 
contain valuable information that may assist surveyors in identifying areas to review 
during the survey.   
  
Surveyors do not look at the potentially avoidable event report in a vacuum.  They 
review this report in light of the actual circumstances surrounding the delivery of care 
to the specific patients.   
  
As a part of the CoPs (484.16, Group of Professional Personnel and 484.52, 
Evaluation of the Agencys Program), HHAs are required to conduct an annual  evaluation of their total program, including patient services.  HHAs are also required 
to conduct quarterly clinical record reviews to evaluate the care provided under the 
HHAs policies.  The CoPs require an agency to have policies and procedures to 
promote patient care that are appropriate, adequate, effective and efficient.  HHAs 
have access to the OBQM reports and the OBQI reports and may incorporate a review 
and investigation of these reports into their evaluation and patient care review 
programs and include them as part of their quarterly record review.  
 
3.  Risk Adjusted OBQI Reports 
 
The risk adjusted OBQI reports are the third and final of the OASIS-based reports.  
These agency-level reports allow individual HHAs to assess their own performance 
with respect to patient outcomes and compare their performance to a national reference 
or benchmark.  In addition, HHAs can use the OBQI data to target and develop plans 
of action to improve or maintain HHA performance and patient outcomes.  The risk 
adjusted OBQI reports became available to all HHAs in February 2002. 
 
CMS anticipates that HHAs will choose to use the OBQI reports for quality improvement 
and for consumer education.  In CMS-sponsored demonstrations where the OBQI process 
has been tested, many HHAs have demonstrated significant improvements in targeted 
patient outcomes. These data rich reports now represent a decade of benchmarking that is 
risk adjusted for each HHA.  This means that every HHA can be compared to the national 
reference values, regardless of the types of patients it serves, when compared to another 
HHA.  Therefore, an HHA that strives to provide quality care services to its patients will 
be able to determine its performance and to identify areas for improvement or 
reinforcement with the quality reports available to them. 
 
Process Measures were added to the OASIS in 2010. For further information, refer to the 
PBQI Manual which is located at: http://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html  
 
The OASIS C Process Measure Reports are now available in the CASPER Reporting 
System. The reports are located in the OASIS C - Quality Improvement report category. 
 
Resources are located on the following CMS websites:  
 
  PBQI  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html    
  
  OBQI -  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIOASISOBQI.html   
 
 
2202.5A - Using Outcome Based Quality Monitoring (OBQM) and Risk 
Adjusted OBQI Reports in the Survey Process 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OBQM reports consist of the patient-related characteristics and potentially avoidable  event outcome reports, which are derived from the OASIS data that HHAs submit to the 
State.  The agency patient-related characteristics and potentially avoidable event reports 
can be used by HHAs for quality monitoring and improvement purposes.  The risk-
adjusted OBQI reports provide measures of patient care based on all of the OASIS data 
items.  These reports allow an HHA to proceed to outcome enhancement.  It is the 
outcome enhancement activities that allow an HHA to focus its quality (or performance) 
improvement activities on select target outcomes, to investigate the care processes that 
contributed to these outcomes, and to make agency-specific changes in clinical actions 
that will lead to improved patient outcomes.  Using these reports is a first step toward full 
implementation of the OBQI program.  As a part of the pre-survey preparation, surveyors 
should access and review the OBQM and OBQI reports before surveying an HHA.  These 
reports contain valuable information that may assist surveyors in identifying areas to 
review during the survey and possibly identify individuals or types of patients to include 
in the sample selection when on site following guidance provided in the Home Health 
Survey Protocol Enhancements, effective May 1, 2003 published February 13, 2003 as 
S&C Memorandum 03-13.  The OBQM Manual, (titled Quality Monitoring Using Case-
Mix and Adverse Event Outcome Report available on the OASIS Web site), provides 
examples of possible surveyor actions related to adverse event outcomes.  The OBQI 
Manual (titled Outcome-Based Quality Improvement Implementation Manual provides 
guidance to HHAs for establishing a quality improvement program using the risk-adjusted 
OBQI reports.  This manual is also available on the OASIS Web site. 
 
1.  Agency Patient-Related Characteristics Report 
 
The agency patient-related characteristics report presents a picture, or snapshot, of an 
HHAs patients at the beginning of a care episode for the time period selected for the 
report.  The beginning of a care episode is marked by either a SOC assessment or a 
ROC assessment.  The body of the case-mix report describes the characteristics of an 
HHAs Medicare and Medicaid patients receiving skilled services compared to the rest 
of the Medicare and Medicaid patients receiving skilled home health services across 
the country during the same time period.  Surveyors should review the case-mix 
outcome report as described in the OBQM Manual and the Appendix titled 
Guidelines for Reviewing Agency Patient-Related Characteristics and Potentially 
Avoidable Event Reports.  Any significant results should be identified after 
reviewing the report, and highlights noted.  This will allow surveyors to begin to 
identify potential clinical groups of patients that can be included in the case-mix 
stratified sample for record review and home visits, as part of the onsite survey. 
 
2.  Potentially Avoidable Event Reports 
 
The Potentially Avoidable Event Report displays incidence rates for untoward events 
(or outcomes) comparing one HHAs patients to patients in the CMS OASIS National 
repository for the same time period. 
 
Potentially avoidable events serve as markers for potential problems in care because of 
their negative nature and relatively low frequency.  The Patient Listing can be used to 
investigate the care processes that contributed to these outcomes and to make agency-
specific changes in clinical actions that will lead to improved patient outcomes.  As a  part of the pre-survey preparation, surveyors should access and review the OBQM and 
OBQI reports before surveying an HHA.  These reports contain valuable information 
that may assist surveyors in identifying areas to review during the survey. 
 
Surveyors do not look at the potentially avoidable event report in a vacuum.  They 
review this report in light of the actual circumstances surrounding the delivery of care 
to the specific patients. 
 
As a part of the CoPs (484.16, Group of Professional Personnel and 484.52, 
Evaluation of the Agencys Program), HHAs are required to conduct an annual 
evaluation of their total program, including patient services.  HHAs are also required 
to conduct quarterly clinical record reviews to evaluate the care provided under the 
HHAs policies.  The CoPs require an agency to have policies and procedures to 
promote patient care that are appropriate, adequate, effective and efficient.  HHAs 
have access to the OBQM reports and the OBQI reports and may incorporate a review 
and investigation of these reports into their evaluation and patient care review 
programs and include them as part of their quarterly record review. 
 
3.  Risk Adjusted OBQI Reports 
 
The risk adjusted OBQI reports are the third and final of the OASIS-based reports.  
These agency-level reports allow individual HHAs to assess their own performance 
with respect to patient outcomes and compare their performance to a national reference 
or benchmark.  In addition, HHAs can use the OBQI data to target and develop plans 
of action to improve or maintain HHA performance and patient outcomes.  The risk 
adjusted OBQI reports became available to all HHAs in February 2002. 
 
CMS anticipates that HHAs will choose to use the OBQI reports for quality improvement 
and for consumer education.  In CMS-sponsored demonstrations where the OBQI process 
has been tested, many HHAs have demonstrated significant improvements in targeted 
patient outcomes. These data rich reports now represent a decade of benchmarking that is 
risk adjusted for each HHA.  This means that every HHA can be compared to the national 
reference values, regardless of the types of patients it serves, when compared to another 
HHA.  Therefore, an HHA that strives to provide quality care services to its patients will 
be able to determine its performance and to identify areas for improvement or 
reinforcement with the quality reports available to them. 
 
Process Measures were added to the OASIS in 2010. For further information, refer to the 
PBQI Manual which is located at: http://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html  
 
The OASIS C Process Measure Reports are now available in the CASPER Reporting 
System. The reports are located in the OASIS C - Quality Improvement report category. 
 
Resources are located on the following CMS websites:  
 
  PBQI  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/PBQIProcessMeasures.html       
  OBQI -  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIOASISOBQI.html   
 
  OBQM http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIOASISOBQM.html 
 
2202.5B - Case-Mix Stratified Sample 
(Rev. 1, 05-21-04) 
 
Surveyors will continue to select a case-mix stratified sample for record reviews and home 
visits since this requirement is explicitly referenced in 1891 of the Act.  For example, 
surveyors will continue to routinely assess the ability of the HHA to provide quality care 
by conducting the following activities: 
 
  Evaluating the current status of the patient as reflected in the comprehensive 
assessment, plan of care and visit notes; 
 
  Verifying that all drugs and treatments are provided according to a physicians 
order and that the HHA has reviewed all drugs for potential adverse effects and 
drug reactions; 
 
  Reviewing the plan of care to identify whether the HHA used the comprehensive 
assessment to make sound care planning decisions appropriate to the patients 
needs; 
 
  Reviewing the timeliness of services provided to the patient; 
 
  Evaluating the HHAs ability to coordinate care and services; 
 
  Reviewing the patients progress toward the achievement of desired outcomes; 
 
  Verifying that any changes in the patients medical condition were reported to the 
physician and recorded, including documentation of verbal orders with written 
confirmation; and 
 
  Evaluating the appropriateness of patients continuation of services or discharge at 
the time of record review. 
 
However, the scope of patients eligible for the case-mix stratified sample may include 
both current and discharged patients.  Surveyors may also identify clinical areas and select 
patients for review on site as part of their off-site survey preparation.  The outcome reports 
may point to concerns that surveyors need to address during the survey and surveyors will 
now be able to include in the sample patients representing the identified concerns.  
 
The surveyor should continue to use the HHAs current visit schedule (or plans for visits) 
during the week that the surveyor(s) is on site to develop the sample for clinical record  review with home visits.  The sample for clinical record review without home visits may 
include records of patients that have been discharged by the HHA. 
 
2202.5C - Privacy Act Requirements 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
1. SA/RO Use of OASIS Data 
 
Each SA or RO user authorized to access and use the OASIS data or reports derived 
from OASIS data must comply with the provisions governing the privacy and security 
of this Federal information system.  Each user with authorized access to the system, 
records, and reports must agree to effectively maintain CMS approved administrative, 
technical, procedural, and physical safeguards to ensure protection of the 
confidentiality of the patient identifiable data and to prevent unauthorized access to the 
data.  Each user is required to have individual valid user identification and a secure 
password.  Each user is obligated to protect the confidentiality of the OASIS data.  As 
noted in the June 18, 1999, December 27, 2001, and November 13, 2007 Federal 
Register notices of the OASIS system of records: No user shall disclose, release, 
reveal, show, sell, rent, lease, loan or otherwise grant access to the data to any person.  
The Federal Privacy Act of 1974 provides criminal penalties and fines for certain 
violations.  The November 13, 2007 Notice describes routine uses. 
 
2.  HHA Use of OASIS Data  
 
The HHAs are required, as a part of the CoPs to maintain the confidentiality of all 
patient identifiable information contained in the clinical record, including OASIS data 
and reports, and may not release patient identifiable OASIS information to the public.  
Therefore, neither the State nor the HHA may release any of the OBQM or OBQI 
reports or the information contained in them. 
 
2202.5D - Accessing the OBQM, OBQI, and Process Based Quality 
Improvement (PBQI) Reports 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The authorized SA and RO user needing access to these reports must have a valid user 
identification and a secure password.  These are obtained by submitting a request to the 
CMS Central Office via the State system coordinator through the CMS RO.  Approved 
requests will be assigned the required user identification and password.  SAs and ROs will 
access the OBQI, PQBI and OBQM reports from the Certification and Survey Provider 
Enhanced Reports (CASPER) link located under the CASPER title on the QIES to 
Success Web site.  The CASPER Home page will display, requiring entry of the login ID 
and password necessary to access the reporting tool.  For most SA and RO users, this 
login ID and password are the same that are currently used when accessing the OBQM 
Reports.  HHAs access their OBQI and OBQM reports in the same way they access their 
OASIS validation reports, by connecting to the OASIS State System via the CMSnet and 
selecting the applicable menu option. 
  The CASPER Reporting Users Guide is located on the state OASIS Welcome page. 
 
2202.5E - Role of the OASIS Coordinators in OBQI 
(Rev. 1, 05-21-04) 
 
The OASIS coordinators work directly with the HHAs to help them access and review the 
OBQM, risk-adjusted OBQI, and Data Management System reports.  In addition, the 
OASIS Coordinators support and train State surveyors to access, review, and interpret the 
reports as needed.  States do not advise HHAs on which outcomes to target nor do they 
provide advice on care practices. 
 
2202.6 - OASIS Instructions 
(Rev. 1, 05-21-04) 
 
2202.6A - OASIS Guidance Manual 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OASIS Manual was intended for use by HHAs in implementing the regulations for 
comprehensive patient assessments, including data collection and reporting using the 
OASIS. 
 
The original OASIS Users Manual, Implementing OASIS at an HHA to Improve Patient 
Outcomes, has been archived and can be found at the following web address:  
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIArchives.html  
 
The current OASIS manual is the OASIS Guidance Manual and can be found at: 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html. 
 
The OASIS Guidance Manual provides guidance for HHAs on how to ensure the 
collection of high-quality (accurate) OASIS-C data.  It includes both general data 
collection conventions and item-specific guidance, as well as links to quality-related 
resources for agencies. It is a streamlined and updated version of the original OASIS 
Implementation Manual.  It covers the overall OASIS implementation process from a 
clinical and management perspective and includes detailed information needed to train 
HHA clinical staff to use OASIS as part of the comprehensive assessment and materials to 
assist operationally in the implementation of OASIS data collection and data reporting. 
While the manual has been revised several times over the past decade to reflect changes to 
the OASIS, the basic structure of the manual has not changed.  It provides: 
 
  Specific item-by-item information on completion of each OASIS item; 
  General information relevant to OASIS data collection versions of OASIS-C for 
each OASIS data collection time point; 
  Sample pages of clinical record forms for OASIS data time points illustrating how 
the relevant OASIS items can be integrated; 
  Relevant resources for HHAs, with hyperlinks when available;    Information on OBQI; 
  Home health care regulations related to OASIS data collection; and 
  Recommendations for ensuring accuracy of OASIS data. 
 
Additional Manuals associated with OASIS: 
 
  The Outcome-Based Quality Monitoring (OBQM) Manual can be used in the 
agencys quality improvement program.  The two reports discussed in this manual 
have been renamed.  The Agency Patient-Related Characteristics Report (formerly 
the Case Mix Report) presents characteristics of the agencys patients at the start or 
resumption of care.  Potentially Avoidable Event Reports, (formerly the Adverse 
Event Outcome Report) displays incidence rates for infrequently occurring 
untoward events (outcomes). 
  The Outcome-based Quality Improvement (OBQI) Manual is written for 
agencies wishing to implement activities to improve or maintain OASIS outcomes.   
 
  The Process Based Quality Improvement (PBQI) Manual is written to assist 
agencies with the use of the process measure reports which can be used in their 
annual program evaluation or internal quality improvement activities.  This could 
include the development of and use of best practices within the agency. 
 
  OASIS National Automation Project: HHA System Users Guide covers the 
data submission process for HHAs, including how they are to access the OASIS 
State System, procedures for electronically submitting data (including corrections 
of previously submitted data), and interpretation of feedback reports from the 
OASIS State System. Materials are updated as needed.  Updates are posted on both 
the CMS and the QIES Technical Support Office (QTSO) websites. 
  OASIS HAVEN System Reference Manual covers the use of HAVEN software, 
which was developed to provide HHAs with software for data entry, editing, and 
validation of OASIS data.  It includes information on setting up the software, 
defining agency and employee information, entering patient and assessment data, 
and data management functions.  This manual, in electronic form, is also included 
with the HAVEN software. These are updated as needed and updates are posted on 
both the CMS and QTSO websites. 
 
As updates are made to the OASIS Manuals, States are notified through the CMS 
contractor of any updates.  In addition, all updates to the manuals are posted on the CMS 
and QTSO Web site. 
 
2202.6B - Other Manuals 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
For SAs only, there is a detailed Users Manual for SA System Administrators who, 
pursuant to the regulations, are required to administer and maintain the OASIS system at 
the State level.  This manual includes an overview of the components of the OASIS State 
System and provides the instructions necessary to administer and maintain them. 
    OASIS Validation Report Messages and Descriptions (December 2009).  This 
updated manual provides the HHAs with guidance which describes the types of 
reports and messages they can expect to see in response to their electronic 
submission of OASIS data.  This manual is based on version 2.00 data 
specifications, available in HAVEN 10.0.  This manual assists HHAs in 
interpreting their feedback reports. 
 
  OASIS-B1 HAVEN System Reference Manual (December 2007).  This manual 
addresses the use of the current recommended version of the Home Assessment 
Validation and Entry (HAVEN) System software which is available online.  This 
manual includes information on setting up the software, defining agency and 
employee information, entering patient and assessment data, and data management 
functions. 
 
2202.6C - Other Teaching Tools 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
In addition to the OASIS Guidance Manual for HHAs, there are other sources of 
information available to help States implement OASIS.  They are: 
 
  OASIS-C Educational Resources - http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/EducationalResources.html 
 
  CMS Sponsored Calls - http://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-
Instruments/HomeHealthQualityInits/EducationalResources.html  
 
  OASIS Training - http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/OASIS/Training.html and 
http://surveyortraining.cms.hhs.gov/index.aspx 
 
  QIES QTSO Web site - In addition to the above sources of information available 
to help States implement OASIS, IFMCs QTSO Web site contains current and 
relative OASIS information, training manuals, HAVEN software, software 
patches, slides from past OASIS conferences and video files that can be viewed on 
line at http://www.qtso.com/ 
 
  OASIS Web site - (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/OASIS/index.html) - The CMS OASIS Web site stores 
and disseminates policy and technical information related to OASIS for use by the 
home health community.  The information posted on the OASIS Web site is 
intended to assist HHAs, SAs, software vendors, professional associations, and 
other Federal agencies in implementing and maintaining OASIS as efficiently as 
possible.  CMS continually updates and modifies the OASIS Web site in an effort 
to provide HHAs and other principals with information necessary to understand 
and implement OASIS.    
  OASIS Help Lines - In addition to the OASIS Web site, QTSO Web site, OASIS 
Users Manual, OASIS Training Manual and CBT modules available through each 
SA, HHAs can access help through telephone and e-mail hot lines: 
 
  The telephone hotline for assistance with HAVEN and OASIS data 
submission is: 1-877-201-4721.  This is a toll-free number available from 
7a.m. - 7 p.m. Central Time.  After hours, a voice-mail box is available to 
record inquiries. 
 
  The e-mail address for assistance with HAVEN and OASIS data 
submission is.  help@qtso.com 
 
  SA and RO OASIS staff have different telephone, FAX, and e-mail hot 
lines in place for assistance with their clinical questions concerning 
HAVEN and OASIS data submission.  These hot lines are designed for 
use by SA and RO staff only.  SA personnel should contact their State 
OASIS Coordinator, RO OASIS Coordinator, or central office OASIS 
staff for this information. 
 
  HAVEN System Reference Manual - This manual includes information on 
setting up the software and data management functions. 
 
  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/OASIS/HAVEN.html or https://www.qtso.com/havendownload.html 
 
2202.7 - OASIS and the Home Health Prospective Payment System 
(PPS) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The home health PPS helps to ensure appropriate reimbursements for quality, efficient 
home health care.  Under prospective payments, Medicare pays HHAs a predetermined 
base payment.  This payment is adjusted for the health condition and care needs of the 
beneficiary.  The payment is also adjusted for the geographic differences in wages for 
HHAs across the country.   
 
This and other PPS information is available on the CMS Web site at 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HomeHealthPPS/index.html. 
 
The following are highlights of the home health PPS system: 
 
  Episode - Medicare pays HHAs for each covered 60-day episode of care. As long 
as beneficiaries continue to remain eligible for home health services and episodes 
are not overlapping and are medically necessary, they may receive an unlimited 
number of episodes of care.  Payments cover skilled nursing, home health aide 
visits, covered therapy, medical social services and routine and non-routine  medical supplies.  
 
  Home Health Resource Groups (HHRG) - A case mix methodology adjusts 
payment rates based on characteristics of the patient and his/her corresponding 
resource needs (e.g., diagnosis, clinical factors, functional factors, and service 
needs, etc.).  The 60-day episode rates are adjusted by case mix methodology 
based on payment policy data elements from the OASIS.  The data elements of the 
case mix adjustment methodology are organized into several dimensions such as 
clinical severity factors, functional severity factors, and service utilization factors 
resulting in Home Health Resource Groups (HHRG), a patient payment 
classification described as case mix.   
 
  Request for anticipated payment (RAP) - To ensure adequate cash flow to HHAs, 
the home health PPS has set forth a split percentage payment approach to the 60-
day episode.  The split percentage occurs through the request for anticipated 
payment (RAP) at the start of the episode and the final claim at the end of the 
episode.  For the initial episode, there is a 60/40-split percentage payment.  An 
initial percentage payment of 60 percent of the episode is paid at the beginning of 
the episode and a final percentage payment of 40 percent will be paid at the end of 
the episode, unless there is an applicable adjustment.  For all subsequent episodes 
for beneficiaries who receive continuous home health care, the episodes are paid at 
a 50/50 percentage payment split. 
 
  Outlier - Additional payments will be made to the 60-day case-mix adjusted 
episode payments for beneficiaries who incur unusually large costs. These outlier 
payments will be made for episodes whose imputed cost exceeds a threshold 
amount for each case-mix group. The amount of the outlier payment will be a 
proportion of the amount of imputed costs beyond the threshold.  Total national 
outlier payments for home health services annually will be no more than a fixed 
percent of estimated total payments under home health PPS. 
 
  Partial episode payment (PEP) - The partial episode payment allows the 60-day 
episode clock to end and a new clock to begin if a beneficiary transfers to another 
HHA or is discharged with goals met but returns because of a decline in their 
condition to the same HHA within the 60-day episode. When a new 60-day 
episode begins, a new plan of care and a new assessment are necessary. The 
original 60-day episode payment is proportionally adjusted to reflect the length of 
time the beneficiary remained under the agency's care before the intervening event.  
The new episode is paid an initial episode payment rate.  The 60 day clock is 
restarted. 
 
  Consolidated billing - Under the PPS a HHA must bill for all Medicare home 
health services which includes nursing and therapy services, routine and non-
routine medical supplies, home health aide and medical social services, except 
durable medical equipment (DME). DME is excluded from the consolidated billing 
requirement. The law requires that all home health services paid on a cost basis be 
included in the PPS rate. Therefore, the PPS rate will include all nursing and  therapy services, routine and non-routine medical supplies, and home health aide 
and medical social services. 
 
  Low Utilization Payment Adjustment, (LUPA) - An episode with four or fewer 
visits is paid as a LUPA, which is the national per visit amount by discipline 
adjusted by the appropriate wage index based on the site of service of the 
beneficiary.  Such episodes of four or fewer visits are paid the wage adjusted per 
visit amount for each of the visits rendered instead of the full episode amount.  
Beginning January 1, 2008, an additional payment is made for the first visit in a 
LUPA episode.  Payment rule refinements often impact policy and are published 
annually at: http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-
HHA-Center.html. 
 
Exceptions to OASIS Collection and Reporting Procedures Under PPS 
 
There are some exceptions to the general OASIS collection and reporting procedures that 
are unique to Medicare PPS patients.  There is information on the OASIS Web site that is 
provided to help HHAs integrate the home health PPS into their existing OASIS data 
collection procedures.  A summary of that information with regard to OASIS data 
collection and the appropriate M0100 (Reason for Assessment) and M2200 (Therapy 
Need) response selection is provided below. 
 
A - PPS Start-up 
 
For new patients after October 1, 2000, any applicable (skilled care) patients (not just 
Medicare patients) accepted for care on or after October 1, 2000, are assessed according to 
the established time points at 484. 
 
EXAMPLE:  A patient whose SOC date is October 15 would be re-assessed for the need 
to continue services for another certification period during the last 5 days of the current 
60-day certification period. In this example, the follow-up assessment would be conducted 
during the period 12/9/00 through 12/13/00. 
 
B.  First 60-day Episode 
 
SOC:  M0100 = RFA 1 and M2200 = 0-No or 1-Yes. 
 
C.  New 60-day Episode Resulting From Discharge With All Goals Met and Return 
to Same HHA During the 60-Day Episode.  (PEP Adjustment) 
 
SOC:  M0100 = RFA 1 and M2200 = 0-No or 1-Yes. 
 
D.  New 60-Day Episode Resulting From Transfer to HHA With No Common 
Ownership  (PEP Adjustment to Original HHA) 
 
PEP Adjustment does not apply if patient transfers to HHA with common ownership 
during a 60-day episode.  Receiving HHA completes OASIS, as applicable, on behalf of  transferring HHA.  Transferring HHA serves as the billing agent for the receiving HHA.  
Transferring HHA may continue to serve as the billing agent for receiving HHA or 
conduct a discharge assessment at end of episode.  Receiving HHA starts new episode 
with SOC (if original HHA discharges at end of episode): M0100 = RFA 1 and M0825 = 
0-No or 1-Yes. 
 
E  Subsequent 60-Day Episode Due to the Need for Continuous Home Health Care 
After an Initial 60-Day Episode 
 
Recertification (Follow-up):  (M0100) = RFA 4 and (M2200) select 0-No or 1-Yes. 
 
F.   Patients Inpatient Stay Extends Beyond the End of the Current Certification 
Period. (Patient Returns to Agency After Day 60 of the Previous Certification 
Period) 
 
SOC: M0100  = RFA 1 and M2200 = 0-No or 1-Yes.  When patient returns home, 
new orders and plan of care are necessary.   
 
At time of transfer to an inpatient facility, the HHA completes the transfer.  If 
transferred without discharging, a new episode is started and a new SOC assessment 
is completed when the patient returns home. 
 
2202.8 - Surveying for the OASIS Requirements 
(Rev. 1, 05-21-04) 
 
The comprehensive assessment regulation requires that HHAs use a standard core data set, 
i.e., OASIS, when evaluating adult, non-maternity Medicare and Medicaid patients 
(except those receiving exclusively homemaker or chore services.)  The OASIS meets the 
condition specified in 1891(d) of the Act, which requires the Secretary to designate an 
assessment instrument in order to evaluate the extent to which the quality and scope of 
services furnished by the HHA attained and maintained the highest practicable functional 
capacity of the patient as reflected in the plan of care.  These regulatory changes are an 
integral part of CMS efforts to achieve broad-based improvements in the quality of care 
furnished through Federal programs and in the measurement of that care. 
 
Since the requirement to report OASIS data to the OASIS State System is not part of the 
standard survey process, while determining compliance with the comprehensive 
assessment of patients is, both offsite and onsite monitoring are required to determine 
compliance with the OASIS CoPs.  The State OASIS Educational and Automation 
Coordinators can assist with the offsite monitoring for OASIS compliance and in 
providing available OASIS reports, (e.g., data management, quality monitoring and 
quality improvement reports) to surveyors.  HHAs that do not collect and report accurate 
and complete OASIS data for all applicable HHA patients risk citations at the standard 
and condition levels.  HHAs found not to be in compliance may be subject to enforcement 
actions and/or termination from the Medicare program.  
 
2202.8A - Condition of Participation: Comprehensive Assessment of  Patients (See 484.55) 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
This CoP states that a comprehensive assessment of the patient, in which patient needs are 
identified, is a crucial step in the establishment of a plan of care.  In addition, a 
comprehensive assessment identifies patient progress toward desired outcomes or goals of 
the care plan.  HHAs complete the OASIS items as part of the clinicians total assessment 
process.  This process is not based solely on interviewing the patient.  Conducting a 
patients comprehensive assessment involves both observation and interview.  These data 
collection techniques complement each other.  Many HHA clinicians begin the assessment 
process with an interview by sequencing questions to build rapport and trust.  Others 
choose to begin the assessment process with a familiar procedure such as taking vital signs 
in order to demonstrate clinical competence to the patient before proceeding to the 
interview.  HHAs are expected to complete all OASIS items as accurately as possible 
while minimizing burden and intrusion on the patient.  
 
HHAs should not force patients to cooperate with the assessment process; rather, they 
must do the best they can to assess patients who do not fully cooperate with the 
assessment process.  Since collecting OASIS information rarely depends solely on patient 
interview, HHAs are expected to complete, encode, and transmit all OASIS data items.  If 
patients refuse to answer some questions that are part of the OASIS assessment, HHAs 
may still deliver care to the patient as long as they complete and submit the OASIS 
assessment to the best of their ability. 
 
States may advise HHAs that seem to report difficulty with specific OASIS items to 
review the processes of performing a comprehensive assessment with their staff.  
Sometimes such difficulties indicate that staff might benefit from additional training or 
retraining in assessment skills.  The OASIS Web-based Training Internet site provides 
additional guidance on OASIS and the Comprehensive Assessment and How to 
effectively conduct a comprehensive assessment for clinicians who are challenged by 
these activities. 
 
As stated in the CoPs, each patient (except those under 18; receiving maternity services; 
receiving only services such as homemaker or chore services; or, until sometime in the 
future, receive personal care services only), regardless of payer source, is expected to 
receive from the HHA a comprehensive assessment that accurately reflects the patients 
current health status and incorporates the exact language of the OASIS data items required 
for the time points specified in this condition.  
 
The requirement to collect OASIS data as part of the comprehensive assessment for non-
Medicare /non-Medicaid patients is temporarily suspended, effective December 8, 2003, 
as a provision of the Medicare Prescription Drug, Improvement and Modernization Act of 
2003.  HHAs must continue to comply with the aspects of the regulation at 484.55 
regarding the comprehensive assessment of patients.  HHAs must provide each agency 
patient, regardless of payment source, with a patient-specific comprehensive assessment 
that accurately reflects the patients current health status and includes information that 
may be used to demonstrate the patients progress toward the achievement of desired  outcomes.  The comprehensive assessment must also identify the patients continuing 
need for home care, medical, nursing, rehabilitative, social, and discharge planning needs. 
 
  HHAs may continue to collect OASIS data on their non-Medicare/non-Medicaid 
patients for their own use. 
 
  Surveyors must continue to examine the completeness of the comprehensive 
assessment for all patients during a survey.  However, surveyors must not 
investigate whether the HHA included the specific OASIS items in its patient-
specific comprehensive assessments of non-Medicare/non-Medicaid patients, nor 
cite deficiencies based solely on this finding. 
 
The CoP is comprised of the following five standards. 
 
1.  Initial Assessment Visit 
 
This standard requires that an initial visit be performed to determine the immediate care 
and support needs of the patient.  The initial assessment visit requirement is intended to 
confirm beneficiary eligibility, to ensure that the patients most critical needs for home 
care services are identified and met in a timely fashion, and to perform the skilled care that 
was ordered.  It is not required that a SOC comprehensive assessment be completed at this 
visit, although the HHA may choose to do so.  If the HHA does not complete the SOC 
comprehensive assessment during the initial visit, then the comprehensive assessment 
must be completed and updated according to the required time points.  
 
  The initial assessment visit is conducted by a registered nurse and must occur 
either within 48 hours of referral or within 48 hours of the patients return home 
from a hospital stay of 24 hours or more for any reason other than diagnostic 
testing, or on the SOC date ordered by the physician. 
 
  For Medicare patients, the initial assessment visit must include a determination of 
the patients eligibility for the home health benefit.  Verification of a patients 
eligibility for the Medicare home health benefit including homebound status does 
not apply to Medicaid patients, beneficiaries receiving Medicare outpatient 
services, or private pay patients. 
 
  When rehabilitation therapy (speech-language pathology, physical therapy, or 
occupational therapy) is the only service ordered by the physician, and if the need 
for that service establishes program eligibility, the initial assessment visit may be 
made by the appropriate rehabilitation professional.  For the purpose of the initial 
visit, a therapy case that includes knowledge of skilled nursing for a one-time visit 
to remove sutures or draw blood is not considered a therapy-only case.  The initial 
visit must be conducted by the qualified registered nurse.  
 
NOTE:  While Medicare pays for occupational therapy, eligibility for the Medicare home 
health benefit cannot be established based solely on the need for that service.  The need 
for occupational therapy does not establish eligibility for the Medicare home health  benefit.  However, the Medicare home health patient with multiple service needs can 
retain eligibility if, over time, the only remaining need is for occupational therapy.  
Therefore, under the Medicare benefit, the Occupational Therapist (OT) cannot conduct 
the initial assessment.  An OT can conduct the Follow-Up assessment and those associated 
with transfers and discharges.  Occupational therapy, could, however, establish eligibility, 
in some States, under the Medicaid program.  In the case of Medicaid patients (or 
Medicare patients receiving therapy services), if the need for a single therapy service 
either establishes eligibility or allows eligibility to continue once it is otherwise 
established, the corresponding practitioner, (including a PT, SLP, or OT) can conduct any 
of the designated assessments. 
 
2. Completion of the Comprehensive Assessment 
 
  When a patient is first admitted to the HHA, a comprehensive assessment must be 
completed no later than 5 calendar days after the SOC date.  The comprehensive 
assessment for all Medicare and Medicaid patients receiving skilled services must 
include OASIS data.  OASIS data is not required for non-Medicare/non-Medicaid 
patients at this time.  However, HHAs may include OASIS data if they choose.  
Additional comprehensive assessments are required throughout a patients course 
of treatment. 
 
  A registered nurse must complete the comprehensive assessment and, for Medicare 
patients, confirm eligibility for the Medicare home health benefit.  
 
  When physical therapy or speech-language pathology is the only service ordered 
by the physician, the PT or SLP may complete the comprehensive assessment.  For 
the purpose of the SOC comprehensive assessment, a therapy case that includes 
skilled nursing for a one-time visit to remove sutures is not considered a therapy-
only case.  The SOC assessment in this case should be conducted by the qualified 
registered nurse but may be completed by the qualified therapist at subsequent 
time points.  The same discipline is not required to complete the subsequent 
assessments at every required time point.  The HHA can decide how best to 
approach the assessment process at the required time points.  For other than 
Medicare, OTs may complete the SOC assessment when the need for occupational 
therapy establishes program eligibility.  (See NOTE above concerning eligibility 
for the home health benefit and occupational therapy services.) 
 
  The SOC comprehensive assessment may be completed in more than one visit as 
long as it is completed within the 5-day time frame required by the regulations. 
 
  Non-clinical staff, i.e., those not qualified by current regulation, may not assess 
patients or complete assessment items; however, non-clinical staff or data entry 
operators may enter the OASIS data collected by the qualified skilled professional 
into the computer.  Many elements in the Clinical Records Items section (which 
identifies the patient) of each OASIS data set may be completed initially by 
clerical staff as part of the intake/referral process; but should be verified by the 
qualified clinician doing the assessment.   
Master of Social Work Only Evaluations 
 
Visits for medical social work assistance only are frequently requested by case managers.  
A visit for medical social work in order to evaluate the patients need or eligibility for 
community services generally is not considered a visit to conduct a comprehensive 
assessment of the patient and would not solely qualify a patient for Medicare home care 
eligibility.  If a physical assessment of the patient is conducted, as is required by the 
comprehensive assessment regulations, it must be done by a qualified person.  In this case, 
that qualified person must be an RN, PT, SLP or OT (as applicable). 
 
Drug Regimen Review 
 
The drug regimen review requirement was moved from the previous plan of care 
requirements to the new comprehensive assessment requirement to reflect the true nature 
and purpose of this activity.  The comprehensive assessment must include a review of all 
medications the patient is currently using in order to determine compliance with drug 
therapy, significant side effects and drug interactions, potential adverse effects and drug 
interactions, ineffective drug therapy, and duplicate drug therapy. 
 
The previous requirements for drug regimen review were modified by eliminating the 
actual identification of adverse actions and contraindicated medications and 
substituting the requirement to review drug therapy compliance, drug interactions, and 
duplicative drug therapy. 
 
3.  Update of the Comprehensive Assessment 
 
In order to have data that is comparable across HHAs, OASIS data must be collected at 
uniformly defined time points including recertification.  This requirement is not expected 
to add to the number of skilled visits provided by the HHA.  Many HHAs arrange visit 
schedules to accommodate home health aide supervisory requirements and patient and 
care giver schedules.  HHAs are expected to similarly adjust the patients visit schedule in 
order to accommodate OASIS time points.  OASIS reassessment visits that are not part of 
a treatment visit are overhead/administrative costs and not separately billable visits.  They 
do not require a physician order. 
 
The comprehensive assessment, which includes the OASIS data items for Medicare and 
Medicaid patients, should be updated and revised no less frequently than: 
 
  During the last 5 calendar days of the current 60-day certification period beginning 
with the SOC date (Follow-up OASIS data set); or within 48 hours of (or 
knowledge of) the patients return home from a hospital stay of 24 hours or more 
for any reason except diagnostic tests (ROC OASIS data set).  If these two 
assessment time periods fall within the five day window, only the ROC assessment 
must be completed; 
 
  Within 48 hours of (or knowledge of) transfer to an inpatient facility (Transfer to  an Inpatient Facility OASIS data set, with or without agency discharge);  
 
  Within 48 hours of (or knowledge of) the patients return home from an inpatient 
stay other than a hospital.   (See major decline or improvement in the patients 
health at 4. below;) 
 
  Within 48 hours of (or knowledge of) discharge to the community or death at 
home (Discharge OASIS data set); and 
 
  For non-Medicare/non-Medicaid patients, HHAs must provide each agency patient 
with a patient-specific comprehensive assessment at the above time points to 
accurately reflect the patients current health status and the patients progress 
toward achievement of desired outcomes. 
 
In a case involving more than one discipline, the SOC assessment should be conducted by 
the qualified registered nurse but may be conducted by the qualified therapist at 
subsequent time points.  The same discipline is not required to complete the subsequent 
assessments at every required time point.  The comprehensive assessment updates should 
include the appropriate OASIS items as indicated on the data set for the respective time 
points, (i.e., SOC, ROC, Follow-Up, transfer to inpatient facility with or without 
discharge, discharge, and death at home). 
 
If home health care is resumed after an inpatient stay, the comprehensive assessment must 
include the OASIS items appropriate for assessment after an inpatient stay.  If the patient 
is not formally discharged at the time of transfer to an inpatient facility, the agency 
completes a comprehensive assessment that includes the ROC OASIS data items. 
 
If the patient is formally discharged from the HHA, the data collection proceeds on the 
basis of a new agency SOC date that follows the inpatient stay; therefore, a SOC 
comprehensive assessment is conducted.  The ROC and SOC (minus the Patient Tracking 
Sheet) OASIS data sets are actually the same data set.  For purposes of OASIS data 
collection, the HHA can establish its own internal policies regarding criteria for formal 
discharge versus interrupting home care services but maintaining the patient on the HHA 
admission roster, i.e., placing the patient on hold status. (See OASIS and the Home 
Health Prospective Payment System for exceptions to this general rule.) 
 
If the patient is under the care of the HHA and is not formally discharged prior to the end 
of the current 60-day period, the HHA conducts the next comprehensive assessment 
during the last 5 days of the current 60-day period beginning with the original SOC date.  
For example, if the SOC date were June 25, 2014, the patient would be reassessed 
between August 18 and August 22, 2014. 
 
If the HHA transfers a patient to an inpatient facility and places the patient on hold 
status, no further assessments are conducted and no data is collected while the patient is in 
the inpatient facility.  The HHA is not providing care while the patient is on hold during 
the inpatient stay.  At the time the patient is transferred to the inpatient facility, a transfer 
assessment (response 6 selected for M0100) is completed.  When the patient returns to  home care, the HHA completes the ROC assessment (response 3 selected for M0100).  
(See OASIS and Home Health Prospective Payment System for exceptions to this general 
rule.) 
 
The ROC assessment is required within 48 hours of the patients return home from the 
inpatient facility unless otherwise determined by physicians orders.  The Follow-up 
assessment is required during the last 5 days of the current 60-day (recertification) period.  
It is possible for these two time periods to overlap.  If they do, M0100, ROC (response 3), 
should be marked.  If these two periods DO NOT overlap, two comprehensive 
assessments should be completed in accordance with the regulations.  One assessment is 
done for the ROC while the other is done for the follow-up time point.  (See OASIS and 
Home Health Prospective Payment System for exceptions to this general rule.) 
 
4.  Major Decline or Improvement in the Patients Health Status 
 
The OASIS regulations require that assessments with OASIS data collection be performed 
at certain time points.  In the event an HHA determines that a patients condition has 
improved or deteriorated significantly at a point in the episode of care that is not already 
captured at a required time point, the HHA should collect and report additional assessment 
information.  Each HHA should define major declines or improvements in the patients 
health status.  Thus, the term major decline or improvement in the patients health status 
is the impetus for collecting and reporting OASIS data to: 
 
  Assess a patient on return from an inpatient facility other than a hospital, if the 
patient was not discharged upon transfer (ROC OASIS data set); and 
 
  As defined by the HHA (Other Follow-up OASIS data set). 
 
5.  Incorporation of OASIS Data Items 
 
Integrating the OASIS items into the HHAs own assessment system in the order 
presented on the OASIS data set facilitates data entry of the items into the data collection 
and reporting software.  Agencies may integrate the items in such a way that best suits 
their assessment system.  Some agencies may wish to electronically collect their OASIS 
data and upload it for transmission to the State.  As long as the HHA can format an output 
file for transmission to the State (that is, in the 1448-byte data string format specified by 
CMS), it doesnt matter in what order it is collected; however, this is not recommended 
because of the skip patterns that are built into the OASIS data set.  In accordance with the 
regulations, data MUST be transmitted in the sequence presented on the OASIS data set.  
The HAVEN software will prompt HHAs to enter data in a format that will correctly 
sequence it and ultimately be acceptable for transmission.  
 
HHAs collecting data in hard copy or electronic form must incorporate the OASIS data 
items into their own assessment instrument using the exact language of the items.  
Agencies are expected to replace similar items/questions on their existing assessment tool 
as opposed to simply adding the OASIS items at the end.  For agencies using software that 
does not accommodate bolding or underlining for emphasis of words in the same manner  as the current OASIS data set, software that capitalizes these words is acceptable, 
including the M numbers when integrating is also recommended.  In this way, the HHA 
will know that the M labeled items are items that MUST be assessed and completed.  This 
will minimize delays in encoding due to incomplete OASIS data items.   
 
HHAs may wish to incorporate the assessment categories (e.g., ADLs/IADLs, 
Medications, etc.) into their own assessment instrument in a different order than what is 
presented on the OASIS data set; however, as stated above, the agency must consider any 
skip instructions contained within the questions in the assessment categories and provide 
the proper instructions. 
 
2202.8B - Record Keeping 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Since the OASIS data set is incorporated into the HHAs comprehensive assessment, the 
clinical record must be maintained according to existing CoPs for clinical records.  
Records of both active and discharged patients must be readily retrievable for use by SA 
staff.   
 
Surveyors may need to ask for orientation to the HHA Electronic Health Record, as 
providers have the right to use whatever system of medical records they choose.  
Surveyors will cooperate and work with facilities that use Electronic Health Records.  
During the entrance conference, surveyors will establish with the agency the process they 
will follow in order to have unrestricted access to the medical record.  Electronic access to 
records will not eliminate the need for a surveyor to print a paper copy or to request a 
paper copy of certain parts of a record.  However, the surveyor shall make reasonable 
efforts to avoid, where possible, the printing of entire records.  The surveyor should print 
or request a paper copy of only those parts of records that are needed to support findings 
of noncompliance, unless protocols for particular types of surveys require otherwise.  
 
Although not required, it is recommended that the HHA print hard copies of the electronic 
validation records received from CASPER and store the validation records in an electronic 
format for twelve months, until the next set of OBQI reports are available.  The validation 
reports may be needed as evidence if the HHA receives a denial from the MAC for 
missing OASIS assessments. 
 
The OASIS Activity Report in CASPER provides a list of assessments that were 
submitted and accepted by a HHA in the previous calendar month.  Information provided 
in these activity reports includes Patient ID, SSN, Patient Name, RFA, Effective Date and 
Submission Date.  This report is generated automatically on the 5th of each month.  
Rejected records are not reported within the Activity Report as the patient information is 
not stored for rejected records. 
 
The activity reports can be found with the validation reports under the naming convention 
of ARmmyyyy.txt.  For example reports completed with data submitted and accepted in 
the month of September 2010 will display as AR092010.txt.   
  Note:  The Activity Reports are deleted from the state servers on the same cycle as the 
validation reports, therefore it is essential to either save the reports to a secured network as 
a text file OR print and save the report. 
 
2202.8C - Condition of Participation: Reporting OASIS Information 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Except as specified in the June 18, 1999 notice, HHAs must report OASIS data on all 
patients (except those under 18, those receiving maternity services, and those receiving 
housekeeping or chore services only) in a format that meets CMS specifications.  HHAs or 
contracted entities acting on behalf of the HHA can report OASIS data to the SA using the 
HAVEN software CMS provides or by using HAVEN-like software that conforms to the 
same specifications used to develop HAVEN.  Once reported to a CMS central database, 
the compiled, aggregate OASIS data (i.e., outcome reports) can be used by the HHA to 
determine how it is performing in terms of patient outcomes compared with other HHAs.  
 
1. Encoding OASIS Data 
 
HHAs must encode (that is, enter OASIS data into a computer using HAVEN or 
HAVEN-like software) and finalize (make export ready) data entry for all 
applicable patients in the agency within 30 days of the M0090 date of an OASIS 
data set. 
 
Once the OASIS data set has been collected at the specified time points described 
above, HHAs may take up to 30 calendar days after the M0090 date of collection 
to enter the assessment into their computer systems.  For example, if the 
comprehensive assessment is completed on May 1, the data must be encoded by 
May 31.  (HHAs should consider implementing a tracking system that considers 
the window for correcting OASIS assessments that need corrections before 
submission.)  HHAs will enter their OASIS data into their computers using 
HAVEN or HAVEN-like software. 
 
HAVEN will automatically review the data for accuracy and consistency; it will 
alert the HHA to make any necessary changes in order to finalize or lock the data.  
The locking mechanism is necessary to ensure the accuracy of the patient 
assessment at the point in time that the assessment took place.  The locking 
mechanism will prevent the override of current assessment information with future 
information.  HHAs will be prompted by HAVEN to export and store encoded data 
into an electronic file. The export file is transmitted to the State by the HHA. 
 
2. Accuracy of Encoded OASIS Data 
 
Encoded OASIS data must accurately reflect the patients status at the time the 
information was collected.  In preparation for transmission to the State, the HHA 
should ensure that data encoded into the computer is identical to the OASIS data 
items completed by the skilled professional.  HHAs should, therefore, develop 
systems to ensure that encoded data matches the OASIS data items completed by  the skilled professional.  Such a monitoring system could include staff appointed to 
audit sample OASIS records after data is encoded as part of the agencys overall 
quality assurance program. 
 
3.  Transmission of OASIS Data   
 
After being exported to a transmission-ready file, the export ready data should be 
transmitted to the State or CMS contractor.  HHAs transmit OASIS data at least 
monthly.  By the last day of each month, HHAs should electronically transmit all 
OASIS data made export ready during the previous month for each patient (as 
applicable based on M0090 date) to the SA.   
 
NOTE:  CMS requires the encoding and transmission of OASIS information only 
on patients who are receiving Medicare/Medicaid benefits.  This means that for 
patients with payer source (1) Medicare (traditional fee-for-service), (2) Medicare 
(HMO/Managed Care), (3) Medicaid (traditional fee-for-service), or (4) Medicaid 
(HMO/Managed Care) on OASIS item M0150, the HHA must collect, encode and 
transmit all required OASIS information to the SA.  If Medicare/Medicaid is 
contributing to the payment of the patients episode of care, the patient is 
considered a Medicare/Medicaid patient.  The payer source for services provided 
as part of a Medicaid waiver or home and community-based waiver program by a 
Medicare-approved HHA are coded as (3) Medicaid (traditional fee-for-service) at 
item M0150. 
 
For non-Medicare/non-Medicaid patients (patients with only pay sources other 
than M0150 response 1, 2, 3, or 4, the HHA is not required to assess and collect 
OASIS as part of the comprehensive assessment and agency medical record.  
Alternatively, the HHA must use its own comprehensive assessment as the 
requirement to collect OASIS data is temporarily suspended.  Non-Medicare/non-
Medicaid payer sources include private insurance, private HMO/Managed Care, 
self pay, programs funded under the Act: for example, Title III, V, XX, or other 
Government programs. 
 
HHAs must have a computer system that supports transmission of OASIS data via 
the CMSnet to the SA (or other designated location), transmits the export file, and 
receives validation information. CMS provides HHAs access to the CMSnet, a 
private communications network CMS purchased to ensure the security of OASIS 
data transmissions to the State.  Use of the CMSnet allows for all data submitted to 
the OASIS State System to be encrypted during the transmission process 
precluding any unauthorized sources from intercepting identifiable data.  Similarly, 
data reports, which are sent by the OASIS State System to the HHA across the 
CMSnet are also automatically encrypted and decoded.  This network encryption 
occurs automatically when the HHA uses the CMSnet and requires no special 
action on the part of the HHA other than using browser software that supports 
industry standard encryption. 
 
HHAs need two different sets of user identification numbers and passwords; one  set to access the CMSnet and one set to access the OASIS System. User 
identifications and Passwords to access the OASIS State System to submit 
assessments or obtain CASPER reports are now specific to individuals(2) and 
should not be shared. The CMSnet is how HHAs transmit their OASIS data.  
HHAs must install the communications software, which is separate from the 
HAVEN software, which will allow them to access the CMSnet.   
 
1.) The supported version of the dialer/CMS vendor is posted on the CMSNet page 
on https://www.qtso.com/mdcn.html.  The helpdesk that supports the CMS vendor 
is the CMSnet Help Desk.  Their phone number is: 1-800-905-2069 Opt 2.  
In the event that CMS changes telecommunication vendors, updates to 
requirements will be made known on the All State Technical Call and on the 
QTSO website. 
 
2.) Instructions for downloading and installing this software are available on the 
OASIS Web site.  Alternatively, HHAs can call the HAVEN help desk at 1-877-
201-4721 for help in obtaining and installing this software. 
 
When the OASIS System receives a transmission file, it validates the reported 
information while the HHA remains on-line to ensure that some basic elements 
conform to CMS requirements, such as proper format and HHA information.  
Once these file checks are complete, a message indicating whether the file has 
been accepted or rejected is automatically sent back to the HHAs computer via the 
agencys communication link.  If the submission is rejected, an informative 
message is sent to the HHA.  
 
A file may be rejected for a variety of reasons. For example, the HHA Facility ID 
in the header record may be incorrect and not match the Facility ID at the State, or 
the number of records indicated in the trailer record is different from the actual 
number of records submitted.  The HHA needs to make the corrections and re-
submit the file to the State.  If the submission passes the initial validation check, 
the file is checked further for errors or exceptions to the data specifications and a 
Final Validation Report is generated up to 48 hours later. 
 
4.  Data Format 
 
The format used for encoding and transmitting OASIS data should conform with 
software available from CMS or other software that conforms to the CMS standard 
layout, edit specifications, and data dictionary including the OASIS data set.   
Details regarding these specifications are available on the OASIS Web site.  The 
software must also include the most current version of the OASIS data items which 
will be available on the OASIS Web site at all times.  CMS provides registered 
HAVEN users with instructions for any revised HAVEN software.  
 
HAVEN will prompt the user to enter the data items associated with a required 
time point by providing the user with the correct screens for the specific type of 
assessment data required.  HHAs will be able to use HAVEN to encode OASIS  data, maintain agency and patient-specific OASIS information, and create export 
files to submit OASIS data to the OASIS System.  HAVEN provides 
comprehensive on-line help for encoding, editing, and transmitting these data sets.  
Additionally, the HAVEN help line (1-877-201-4721) is available to HHAs with 
questions concerning the installation and use of HAVEN.  
 
The export function in HAVEN produces an ASCII text file from the HAVEN 
database.  The file meets the OASIS data specifications that must be transmitted to 
the system. The OASIS System will reject all assessments with a non-
Medicare/non-Medicaid payment source; therefore HAVEN will not include these 
assessments in the export file. 
 
The following chart summarizes the required time points and time frames outlined in the 
regulations for collection, encoding, and reporting OASIS data. 
 
OASIS ASSESSMENT REFERENCE SHEET 
 
RFA = Reason For Assessment 
 
         
RFA  RFA Description  Assessment Completed  Locked  Submission Timing 
Type  Date 
01  SOC - further  Within 5 calendar days  Effective  Effective 6/21/2006 
visits planned  following the SOC Date  6/21/2006  Transmission required 
(M0030)  No  within 30 calendar days of 
required  completing the assessment 
lock date  (M0090) 
02  SOC - no further  Within 5 calendar days     
visits planned  following the SOC Date 
(M0030) 
03  ROC - after  Within 2 calendar days     
inpatient stay  following the ROC Date 
(M0032) 
04  Recertification -  Completed (M0090)     
Follow-up  every 60 days following 
SOC:  no earlier than day 
56 and no later than  the 
day (day 60) on which the 
certification period ends 
05  Other Follow-up  Complete assessment     
(M0090) within 2 
calendar days following 
identification of 
significant change of 
patients condition           
RFA  RFA Description  Assessment Completed  Locked  Submission Timing 
Type  Date 
06  Transferred to  Within 2 calendar days     
inpatient facility -  following or knowledge 
not discharged  of disch/trans/death date 
from agency  (M0906) 
07  Transferred to  Within 2 calendar days     
inpatient facility -   following or knowledge 
discharged from  of disch/trans/death date 
agency  (M0906) 
08  Died at home  Within 2 calendar days     
following or knowledge 
of  disch/trans/death date 
(M0906) 
09  Discharged from  Within 2 calendar days     
agency: Not to  following or knowledge 
inpatient facility  of disch/trans/death date 
(M0906) 
 
2202.8D - Condition of Participation:  Release of Patient Identifiable 
OASIS Information 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
This CoP states that an agent acting on behalf of the agency, in accordance with a written 
contract, must ensure the confidentiality of all patient identifiable information contained in 
the clinical record, and may not release it to the public. 
 
The purpose of this provision is to ensure that access to all OASIS data (hard copy as well 
as electronic data) is secured and controlled by the HHA.  This requirement mandates that 
the HHA ensures the confidentiality of all patient identifiable OASIS information 
contained in the clinical record and may not release it for any reason other than for what it 
is intended, which is to transmit to the SA for the development of outcome reports.  The 
HHAs policies should include assignment and maintenance of secure passwords required 
for encoding and transmitting OASIS data.  Policies should narrowly define the 
qualifications of individuals having access to the OASIS software.  For security reasons, 
passwords are required in the HHA for access to the agencys computer system.  A 
separate password is required for transmitting the OASIS data files to the SA.  Privacy and 
confidentiality of OASIS data are extremely important.  Coverage under the Federal 
Privacy Act of 1974 begins when the data reaches the SA.  The Privacy Act protects 
OASIS data from unauthorized use and disclosure and has been effective in ensuring 
confidentiality of Medicare data. 
  HHAs may choose to encode and transmit OASIS data to the SA themselves, or may 
contract with an outside entity (agent) to fulfill these requirements.  Agents acting on 
behalf of the HHA, such as a data entry and submission vendor or contractor, guided by a 
written contract, are bound by the same confidentiality rules.  The HHA is ultimately 
responsible for compliance with the confidentiality requirements and is the responsible 
party if the contractor does not meet the requirements.  HHAs using HAVEN are 
prompted to enter agent information during set up of the HAVEN program. 
 
Data in the hands of an entity contracted by the HHA for data transmission is not covered 
by the protections of the Privacy Act, therefore policies related to the security of the 
OASIS data set are required.  HHAs contracting with outside entities for data submission 
are ultimately responsible for the confidentiality and use of that data.  Agreements 
between HHAs and their contractors should specify that the data is only to be used for its 
intended purpose, that is, to create outcome reports.  As such, identifiable data must be 
treated in accordance with State law and must not be disclosed without patient consent.  
Violations of data confidentiality by an entity contracted by the HHA are the 
responsibility of the HHA and would constitute condition-level non-compliance. 
 
Agents must be aware of the requirements and security policies of the HHA and the SA 
concerning passwords, as well as the requirements of the OASIS System of Records and 
the Privacy Act. 
 
2202.9 - Patient Notification of OASIS Collection and Reporting 
(Rev. 1, 05-21-04) 
 
Under existing patient rights regulations (42 CFR 484.10(a) and (d), the HHA must 
provide the patient with a written notice of the patients rights to confidentiality of 
medical records in advance of furnishing care to the patient.  As part of the patients 
rights, the HHA is required to notify the patient of its policies and procedures for 
disclosure (confidentiality) of clinical records at the time of admission.  The HHA must 
maintain documentation showing that this requirement has been completed; therefore, 
HHAs must develop admission policies that encourage patient compliance with 
assessment procedures.  Failure to collect and report accurate and complete OASIS data 
on all applicable patients places the HHA at risk of losing its Medicare certification.  
States will be able to monitor whether HHAs are submitting the required OASIS 
information through use of data management reports.  While patients have the right to 
refuse to answer questions posed by the HHA, very few OASIS data items rely solely on 
direct patient questioning.  Therefore, HHAs must complete all OASIS data items as best 
they can, using their assessment skills.  
 
2202.9A - Informing Patients of OASIS Collection and Reporting 
(Rev. 1, 05-21-04) 
 
On or after July 19, 1999, HHAs were required to provide existing patients with privacy 
notifications.  To properly inform patients of their rights under the Privacy Act, the 
provider must furnish each patient with information required by the Privacy Act.  Under 
the authority of the Privacy Act, notices must contain the following information:   
  The right to be informed that OASIS information will be collected and the purpose 
of collection;  
 
  The right to have the information kept confidential and secure;  
 
  The right to be informed that OASIS information will not be disclosed except for 
legitimate purposes allowed by the Federal Privacy Act;  
 
  The right to refuse to answer questions; and 
 
  The right to see, review, and request changes on their assessment. 
 
The statements of patient privacy rights with regard to the OASIS collection (one for 
Medicare/Medicaid patients, one for all other patients served by the HHA) are available on 
the OASIS Web site as part of the June 18, 1999, Federal Register notice.  HHAs must 
include these statements as part of their admission information. Effective December 8, 
2003, HHAs who choose to collect OASIS data on their non-Medicare /non-Medicaid 
patients must continue to comply with informing patients with privacy notifications.  
HHAs that do not collect OASIS data on non-Medicare/non-Medicaid patients are no 
longer required to provide the Privacy Act notification. 
 
2202.9B - Right to See, Review, and Request Changes 
(Rev. 188, Issued: 04-26-19, Effective: 04-26-19, Implementation: 04-26-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 
Medicare identification number. For purposes of this manual, Medicare beneficiary 
identifier references both the Health Insurance Claim Number (HICN) and the Medicare 
Beneficiary Identifier (MBI) during the new Medicare card transition period and after for 
certain business areas that will continue to use the HICN as part of their processes. 
 
The Federal Register notice of June 18, 1999, requires that, under the Privacy Act, 
Medicare/Medicaid patients have the right to see, review, and request changes in their 
assessments.  HHAs must accommodate patients (or their representative), who request this 
review.  If the patient disputes OASIS information collected as part of a comprehensive 
assessment, the HHA has two options; it can agree or disagree with the dispute. 
 
1.  The HHA Agrees.--If the HHA agrees with the patients request, it accepts the 
request, and changes the applicable OASIS data item(s) on the assessment.  A 
corrected assessment can be submitted to the State, using the terms of the OASIS 
correction policy.  
 
2.  The HHA Disagrees.--If the HHA disagrees with the patients request, the patient 
should request written documentation that the disputed information will not be 
changed by the HHA including the reason(s) why. 
 
If a patient chooses to pursue his/her request at the Federal level, he/she may contact CMS  at 1-800-Medicare, toll free, for further review of the disputed issue.  The individual 
contesting a record will be advised to write to the Privacy Officer, CMS, 7500 Security 
Boulevard, Baltimore, Maryland, 21244-1850, identify the record, and specify the 
information being contested.  This correspondence must include the HHAs written 
documentation refusing the change.  It must also state the corrective action sought and the 
reasons for the correction with supporting justification.  (These procedures are in 
accordance with the Departments regulations (45 CFR 5b.7.)  To preserve the privacy of 
the OASIS/HHA system of records, the Privacy Act Privacy Officer may require that the 
individual provide the following information for verification purposes:  The system name, 
Medicare beneficiary identifier, and, for verification purposes, the individuals name 
(womans maiden name, if applicable), social security number, address, date of birth, and 
sex.  (Furnishing the social security number is voluntary, but it may make searching for a 
record easier and prevent delay.)  This information must be notarized to preserve the 
confidentiality of this process. 
 
The HHA Medicare/Medicaid patient who wants to know if there is a record belonging to 
him/her in the OASIS/HHA system of records, or wants to review the record contained in 
the CMS OASIS/HHA system of records repository would follow the same process.  The 
patient can contact CMS toll free at 1-800-Medicare to get instructions for how to pursue 
his/her request. 
 
2202.10 - OASIS and HHAs Seeking Initial Certification 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Prior to receiving Medicare approval, HHAs must meet certain requirements, including 
enrollment and capitalization, and must provide skilled home health services to a 
minimum of 10 patients (not necessarily Medicare patients) that is consistent with the 
Medicare home health CoPs.  This includes compliance with the OASIS collection and 
transmission requirements.  New HHAs must demonstrate that they can transmit OASIS 
data prior to the initial certification survey.  Specifically, new HHAs must apply for a user 
identification number and password from the State OASIS automation coordinator in 
order to register for an individual user identification and password which is used to 
electronically transmit to the OASIS System any encoded and locked SOC or ROC 
OASIS assessment record(s) for applicable Medicare and Medicaid patients in a test 
mode.  HHA survey staff must communicate with the OASIS coordinators to determine 
this aspect of compliance prior to the initial onsite survey.  SAs and AOs with deeming 
authority should not schedule initial surveys until the SA or AO has determined the 
HHAs status with the OASIS transmission requirement.  AOs may contact the state 
directly to determine the status of the new HHAs activities concerning the OASIS 
transmission process prior to scheduling the onsite survey.  The names and phone numbers 
of the State OASIS contacts are found on the OASIS Web site. 
 
To acquire an HHA personal login ID, agencies will be required to complete and submit 
the CMSNet Access Request form and the OASIS Individual User Account Request 
form.  The forms are available on the QIES Technical Support Office website 
(https://www.qtso.com/). To meet the OASIS transmission requirements prior to the 
 
initial certification survey, new HHAs need two different sets of user identification  numbers and passwords; one set to access the CMSnet and one set to access the OASIS 
System. 
 
The OASIS automation coordinator in each SA should assist the new HHA in obtaining 
the user identification numbers and passwords and guide HHAs through registration for an 
individual user identification and password prior to the initial certification survey.  Once 
the communications software and access are in place, the new HHA must demonstrate that 
it can transmit OASIS data to the OASIS System by (1) making a test transmission of any 
SOC or ROC OASIS data that passes CMS edit checks; and (2) receiving validation 
reports back from the OASIS System confirming data transmission. 
 
Transmissions of test data prior to the OASIS System successfully uploading the 
certification kit in ASPEN will result in any submission file being processed as a test 
submission.  The user will receive a final validation report showing any warning and fatal 
error messages associated with each record.  However no data will be stored on the 
database until the initial certification kit has been successfully uploaded.  Unless submitted 
as a test, once the certification kit is successfully uploaded all assessment data will be 
treated as live data and stored on the database. 
 
2202.10A - Determining Compliance With the OASIS Transmission 
Requirements 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Depending on the method of transmission the HHA chooses, the SA needs to determine 
compliance in one of the following ways: 
 
  If the new HHA chooses to independently transmit OASIS data from its own 
office, the State HHA survey team and OASIS coordinator must communicate 
with each other to establish that the new HHA has successfully transmitted test 
OASIS data using the appropriate user identification numbers and passwords, prior 
to onsite survey.  The HHA should maintain all copies of validation reports for its 
records. 
 
  If the new HHA chooses to use a software vendor to meet the OASIS encoding 
and/or transmission requirement on its behalf, the HHA must still establish 
connectivity to the OASIS System via the software vendor.  The HHA should have 
a written contract that describes this arrangement.  The vendor and/or other 
certified HHA will need to apply for access to this agency as a Third Party 
Submitter.  Forms are available on QTSO at:  
https://www.qtso.com/accesshha.html. 
 
  The HHA or its software vendor must apply for the applicable user identification 
numbers and passwords from the SA in order to establish connectivity with the 
OASIS System.  As described above, the HHA survey team and OASIS 
coordinator must communicate with each other to establish that the software 
vendor, on behalf of the new HHA, has successfully transmitted test OASIS data 
using the appropriate user identification numbers and passwords, prior to onsite  survey.  The HHA should obtain copies of all validation reports from its software 
vendor for its records. 
 
  If the new HHA chooses to use another certified HHA to meet its transmission 
requirements, for example, another established HHA in the chain or other 
established but non-related HHA, the HHA must still demonstrate connectivity to 
the OASIS System via the other established certified HHA.  The new HHA or 
other HHA must apply for user identification numbers and passwords, unique to 
the new agency, from the SA, in order to establish connectivity with the OASIS 
System. The new HHA must have clearly written policies outlining the procedures 
in place with the other HHA with regard to OASIS collection, encoding and 
submission to the OASIS State System and the sharing of feedback reports from 
the OASIS System with the new HHA. 
 
2202.10B - HHAs Seeking Initial Certification Through Deemed Status 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
An HHA may choose to obtain initial Medicare certification by electing the deemed status 
option through an approved AO that has been granted deeming authority for Medicare 
requirements for HHAs.  There are currently three AOs with deeming authority for HHAs 
- the Joint Commission (TJC), the Community Health Accreditation Program (CHAP), 
and the Accreditation Commission for Health Care, Inc.  HHAs seeking initial 
certification through the deemed status option must still apply to the SA for user 
identification numbers and register as an individual in order to demonstrate compliance 
with OASIS submission requirements prior to approval. 
 
When the SA receives a request from an HHA interested in seeking Medicare deemed 
status through accreditation by an AO with deeming authority, the State ensures that the 
HHA understands its obligation to meet the OASIS requirements, even when the AO 
conducts the initial certification survey.  This includes compliance with the OASIS 
collection and transmission requirements. 
 
If the SA receives a certification packet from an HHA seeking Medicare certification 
based on its accreditation through a deemed status program, it is the SAs responsibility to 
determine that the HHA meets its OASIS transmission responsibilities.  The OASIS 
transmission responsibility may be met in one of the three ways described above. 
 
2202.10C - Exceptions to Demonstrating Compliance With OASIS 
Submission Requirements Prior to Approval 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
New HHAs that intend to admit or treat only patients to whom OASIS currently does not 
apply, i.e., patients under 18, maternity, and patients receiving only unskilled care or chore 
services are not expected to demonstrate compliance with OASIS submission 
requirements prior to approval.  
 
These HHAs must attest this intention to the SA.  After certification, if there is a change in  the HHAs policies that includes the acceptance of patients to whom OASIS applies, the 
HHA is expected to install the necessary communications software and contact the SA and 
CMSnet for the applicable user identification numbers and passwords. 
 
2202.10D - Compliance Dates and PPS 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Compliance with the rest of the CoPs is determined via an onsite survey by the SA and 
any applicable subsequent actions or revisions required of the HHA following the initial 
survey.  After survey, the new HHA cannot bill Medicare for payment of services to 
Medicare beneficiaries until the effective date for Medicare participation has been 
determined by the CMS RO. 
 
Realistically, notification of the effective date may come many weeks after the initial 
survey of the HHA.  In addition, the date of official compliance may vary depending on 
the outcome of the onsite survey.  As described in 2780, the date of compliance is either: 
 
1.  The date the onsite survey is completed if, on the date of the survey the HHA meets 
all CoPs and any other requirements required by CMS; or 
 
2.  If the HHA fails to meet any of the requirements as a result of the onsite survey, 
compliance is the earlier of: 
 
  The date the HHA meets all enrollment requirements; or 
 
  The date the HHA meets all the CoPs and submits an acceptable 
plan of correction for standard level deficiencies. 
 
Payment under Medicare for services provided prior to the effective date for Medicare 
participation is not permitted.  As such, it is important that new HHAs seeking payment 
under Medicare establish the required 60-day episode on or after the effective date of their 
Medicare participation. 
 
2202.10E - Instructions for Handling Medicare Patients in HHAs 
Seeking Initial Certification 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The Medicare OASIS submission and billing process cannot begin until the effective date 
of the HHAs CCN, which is assigned after the RO has done the review of the initial 
survey findings, plan of correction if one was necessary, documentation on whether the 
HHA has met the enrollment requirements, and documentation that the MAC has 
completed the second capitalization review.  Enrollment requirements include completion 
of the CMS Form 855A, first capitalization review, completion of a survey by a SA or RO 
with the HHA in compliance with the CoPs, additional development by the MAC and 
second capitalization review by the MAC.  After it is assigned its CMS certification 
number (CCN) by the RO, the HHA should do a new SOC assessment (RFA 1) on each of 
its Medicare eligible patients.  This assessment visit date should be consistent with the  first billable visit date after Medicare participation becomes effective. 
 
Once the CCN has been assigned, the HHA can go back and encode the collected OASIS 
information, obtain the necessary payment system codes for billing under PPS, and 
transmit the information to the OASIS State System as production (i.e., live) data.  The 
date of this assessment will become day 1 of the HHAs first 60-day episode under 
Medicare, as long as the assessment was done in conjunction with a billable visit.  
Warning messages related to noncompliance with timing requirements are unavoidable 
and are to be expected in this situation. 
 
If compliance (i.e., the effective date) is not the date of the onsite survey, it will be based 
on D.2. above, as further outlined in 2780.  The HHA should, again, do a new SOC 
assessment (RFA 1) on each of its Medicare patients at the first billable visit after the 
anticipated date of compliance, delay encoding and transmitting the assessment until the 
CCN is assigned, and continue as outlined in the paragraph above.  That is, the HHA 
should go back and encode the collected OASIS information, obtain the necessary 
payment codes for billing under PPS, and transmit the information to the OASIS State 
System as production data.  As above, warning messages related to noncompliance with 
timing requirements are unavoidable and are to be expected in this situation. 
 
If the new HHA did not conduct a SOC (RFA 1), ROC (RFA 3), or Follow-up (RFA 4) 
OASIS assessment during the time between the effective date for Medicare participation 
and the date the HHA learns of its approval, the HHA should conduct a SOC assessment, 
as soon as possible.  This assessment can be used to generate the payment code used for 
billing under Medicare.  The SOC date should reflect a date that is consistent with the first 
billable visit after the effective date for Medicare participation, as stated above. 
 
2202.10F - Instructions to New HHAs Concerning all Other Patients 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Non-Medicare and Non-Medicaid patients do not require OASIS collection or 
transmission. 
 
For all other patients treated by the HHA (i.e., non-Medicare or non-Medicaid patients), if 
a new start of care date is not required by the patients payer source, the HHA should 
encode and transmit all OASIS assessments as required by current regulation that were 
collected after the effective date of Medicare participation.  These assessments should be 
submitted in the production mode using the newly assigned provider number.  The HHA 
should continue with the OASIS assessment schedule already established based on the 
patients admission date. 
 
2202.11 - Correction Policy 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
HHAs have the ability to electronically correct nearly all errors found in their production 
OASIS submissions.  SAs should not be accepting requests for manual key field changes.  
Instead, HHAs should use the inactivation procedures to correct assessments containing  key field errors.  HAVEN 5.0 and above will give HHAs the ability to electronically 
correct nearly any kind of assessment errors. 
 
CMS strongly recommends that all HHAs install the most updated version of HAVEN.  
OASIS HAVEN software may be adjusted over time to incorporate changes in system 
components as well as incorporate bug fixes.  Adjustments will be posted to the HAVEN 
Data Entry Software web page on the CMS Web site at:  
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/OASIS/index.html?redirect=/oasis/and on the OASIS State Systems. 
 
Key Fields and Non-Key Fields 
 
A description of key fields is below.  Non-key fields are all other fields making up the 
OASIS data set that are not key fields. 
 
KEY FIELDS 
Patient Identifiers:   
M0040_PAT_LNAME  Patient last name 
M0040_PAT_FNAME   Patient first name 
M0064_SSN  Patient social security number 
M0066_PAT_BIRTH_DT  Patient date of birth 
M0069_PAT_GENDER  Patient gender 
   
HHA Identifiers:   
HHA_AGENCY_ID  Unique Agency ID code 
   
Assessment Event Identifiers:   
M0100_ASSMT_REASON   Reason for completing assessment 
M0090_INFO_COMPLETED_DT  Date assessment information completed (This is a 
key field only on recertification or follow-up 
assessments where RFA = 04 or 05) 
M0030_START_CARE_DT  SOC date (This is a key field only on SOC 
assessments where RFA = 01) 
M0032_ROC_DT  ROC date (This is a key field only on ROC 
assessments where RFA = 03) 
M0906_DC_TRAN_DTH_DT   Discharge, transfer, death date  (This is a key field 
only on transfer to inpatient facility assessments 
where RFA = 06 or 07, death at home assessments 
where RFA = 08 and discharge assessments where 
RFA = 09) 
 
HHAs can electronically correct key field errors in production records in addition to non-
key field errors and also remove erroneous records using an automated methodology 
called inactivation. With the ability to inactivate erroneous OASIS assessments, as 
described below, HHAs will be able to remove assessments from the OASIS State 
Systems active database that have been submitted in error.  These records are not actually 
deleted, but are moved from the active database to a history database that contains records  that have been modified or inactivated.  This approach keeps an audit trail of modified and 
inactivated records, but hides them from the normal OASIS State System reporting 
procedures. 
 
2202.11A - Determining When to Inactivate an Assessment 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
If an error has been made in one or more key fields, or if an assessment was submitted in 
error, the HHA should electronically inactivate it.  Use of the inactivation procedure is not 
applicable to correcting assessments with only non-key field errors.  In other words, if an 
assessment contains errors in only non-key fields, then correction type 3 described at C.3. 
below should be used.  In order to determine whether to submit an inactivation request, the 
user should apply the following rules: 
 
1.  Assessment Submitted in Error 
 
If an assessment was submitted in error (i.e., it should never have been submitted), it 
must be inactivated.  For example, if a discharge assessment was submitted by the 
therapist; however, the patient is still being visited by the nurse, an inactivation request 
must be submitted for the erroneous discharge record.  Another reason to inactivate an 
assessment would be if the submitted assessment contained the wrong patient name. 
 
2.  Error in Key Field 
 
If an assessment was submitted which contained an error in any of the key fields listed 
above, then an inactivation request must be submitted.  Normally, the HHA will also 
submit a new, corrected assessment in this situation. For example, if the HHA 
discovers that the patients last name on the SOC assessment is spelled Smyth, while 
on the Follow-up assessment it is spelled Smith, it needs to make the appropriate 
correction.  When the HHA determines the discrepancy, the incorrect record must be 
inactivated and a new corrected record must be submitted. 
 
3.  Submission of Incorrect Format 
 
Private Pay assessments are now rejected upon submission and do not require 
inactivation. 
NOTE:  There is no automatic mechanism to reactivate a record that has been 
inactivated.  Consider the case where a discharge assessment is submitted to 
the OASIS State System for a patient, but is inadvertently inactivated.  There is 
no means to undo the inactivation and thereby reactivate this discharge.  
Instead the HHA must submit the discharge record again.  An inactivated 
record can only be undone by the re-submission of the record. 
 
2202.11B - Deleting Assessments 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
In certain infrequent situations, inactivation is not sufficient to correct assessment errors  since inactivation alone does not remove the assessment record from the OASIS System.  
Two situations require deletion of an erroneous assessment, rather than inactivation.  
States will need to continue to submit deletion requests on behalf of HHAs, upon request, 
to the CMS Division of National Systems (DNS) contractor when the following situations 
occur. 
 
1.  Assessment Deletion 
 
The HHA submits identifiable data on patients not defined by the OASIS system of 
records. The OASIS repository is limited to the collection of identifiable data on 
patients who are Medicare and/or Medicaid patients receiving skilled care with certain 
exceptions, i.e., under 18 and maternity patients.  In instances where the OASIS 
System has received OASIS data on patients not included as part of the OASIS System 
of Records, the data needs to be deleted.  
 
EXAMPLE:  The HHA checks Response 1, 2, 3, and/or 4 in the Current Payment 
Source (M0150 field) for that assessment record and it should not have.  The record 
is transmitted to the OASIS System and accepted. The HHA determines that the 
response for M0150 is in error. The patient was not a Medicare or Medicaid patient; 
therefore, this data should not be stored on the OASIS database. 
 
EXAMPLE:  The HHA submits an incorrect birth date on a patient who is a year old, 
which was accepted because the birth year identified the patient as being over 18. The 
patient was actually under 18 and the assessment should be deleted. 
 
Deletion Request forms are located on the State password protected Page of the QTSO 
website.  CMS requires the signature of the agency administrator and of the SA before 
the deletion will be processed. 
The HHA must send the Deletion Request Form in writing to the State OASIS 
coordinator to request deletion of an assessment.  The State will then send in writing to 
DNS contractor, the reason this data should be removed from the States database. 
 
*Effective dates are: 
 
M0030_START_CARE_DT for RFA types 01; 
 
M0032_ROC_DT for RFA type 03; 
 
M0090_INFO_COMPLETED_DT for RFA types 04 & 05; and 
 
M0906_DC_TRAN_DTH_DT for RFA types 06, 07, 08, & 09. 
 
2.  File Deletion 
 
The HHA submits a file as Production data instead of Test data.  The State must 
verify the HHAs claim of Production data versus Test data.  The HHA must send  the following information in writing to the State coordinator to request deletion of a 
file: 
 
  HHA Name; 
 
  HHA ID; 
 
  Submission Date/Time; 
 
  Submission Batch ID; and 
 
  Reason this data should be removed from the States database. 
 
The State will then send in writing to the CMS contractor following information to 
request deletion of a file: 
 
  HHA Name; 
 
  HHA ID; 
 
  Submission Date/Time; 
 
  Submission Batch ID; and 
 
  Reason this data should be removed from the States database. 
 
The following events will then take place: 
 
The CMS DNS Contractor will create a report from the above listed information. This 
report will be sent to the State OASIS Coordinator for him/her to verify the accuracy 
of assessment(s) to be deleted from the States database. 
 
  The OASIS Coordinator will notify the CMS DNS contractor that the 
information is accurate and should be deleted from the States database. 
 
  The CMS DNS contractor will consult with CMS on any questionable deletion 
requests. 
 
  The CMS DNS contractor will delete the data upon approval from CMS. 
 
  The CMS DNS contractor will keep a log of all deleted data from each States 
database. 
 
The deletion request information should be communicated to the CMS DNS contractor by 
one of the following methods of communication:  
 
The Deletion Request Form directs states to forward the signed form to the CMS  DNS contractor via certified mail to the address on the form. 
 
The deletion request sheets must be submitted to the CMS DNS contractor by the 
State.  Requests received directly from HHA will not be accepted.  
 
NOTE: This information MUST NOT be sent via e-mail due to the confidentiality of the 
information. 
 
2202.11C - Types of Corrections an HHA Can Make in HAVEN 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
HAVEN offers the following menu of corrections an HHA can make: 
 
1.  Assessment was Submitted to the State and was Rejected 
 
The HHA can unlock the assessment, make the necessary changes, and re-submit it.  
Because of the built-in edit checks, HHAs using the HAVEN software should not 
expect records to be rejected by the OASIS System for this reason.  Note that the 
following examples are provided for illustration purposes to troubleshoot HAVEN-like 
software, but cannot occur in HAVEN. 
 
EXAMPLE 1:  The HHA Agency ID field in one or more assessment records does not 
match the HHA Agency ID in the header record of the submission file.  The entire 
submission file is rejected and no data is loaded into the state database.   
 
EXAMPLE 2:  The patients last name was missing from the assessment file (data 
record).  The HHA may have inadvertently left this field blank.  The OASIS System 
must have the patients last name.  The data record in this example would be rejected 
and no data from this record would be loaded into the state database.  
 
In these examples, the HHA would make the necessary corrections and re-submit the 
record. Since the OASIS System never accepted the original assessment, the correction 
number field IS NOT incremented in this situation.  HHAs may still receive a warning 
if submission/timing guidelines have been exceeded. 
 
2.  Assessment was Submitted to the State and was Accepted.  Correction to Key 
Fields is Necessary 
 
With the implementation of the OASIS System update, this option will display in 
HAVEN but will no longer be available and is disabled in the HAVEN software.  To 
correct an assessment with key field errors, first inactivate the assessment, then create 
a new assessment for re-submission, as applicable.  See correction type 4 below. 
 
3.  Assessment was Submitted to the State and was Accepted.  Correction to Non-Key 
Fields is Necessary 
 
If an HHA determines that a correction(s) must be made to non-key fields only (i.e.,  any fields in the OASIS data set not contained in the key fields listed above), the HHA 
should re-open the assessment, revise the targeted non-key fields, and re-lock and re-
submit the corrected record.  The lock date changes to reflect the date the correction 
was made. 
 
NOTE:  CORRECTION_NUM is a counter field contained in the programming of 
the HAVEN software used to track corrections made to an assessment record.  The 
counter field is set to 00 when an assessment record is initially locked.  The counter 
field is incremented in this case.  Both the original assessment and the corrected 
assessment will be stored in the state database.   
 
4.  Assessment was Submitted to the State and was Accepted.  Inactivation of the 
Assessment is Necessary 
 
This is an option in HAVEN that allows HHAs to correct key field errors by 
inactivating the assessment(s) containing key field errors and re-submitting a new, 
corrected assessment.  Unlike making non-key field changes, as described in 
correction type 3 above, the HHA does not simply unlock the assessment record, make 
the necessary key field changes, re-lock the record, and re-submit it.  Instead, the HHA 
is taken directly to the assessment in question where it can be viewed in a read-only 
format.  While in read-only mode, when the HHA confirms that the assessment should 
be inactivated, HAVEN will ask the HHA to commit to this selection.  The correction 
number field on the HAVEN Management screen displays an X and the assessment 
status is set to Export Ready.  The value of 99 indicates that this assessment has 
been inactivated.  
 
When the HHA selects this correction type, a copy of the original assessment record is 
created.  To re-submit the assessment with the necessary corrections, the HHA first 
exports the assessment that is being inactivated.  From the HAVEN Management 
screen, the HHA then selects the inactivated record in question and clicks on the 
Correct Assessment button. A pop-up box will appear asking if the HHA wants to 
create a new assessment containing data from the inactivated assessment.  When the 
HHA clicks on the OK button, a copy of the original assessment appears.  The HHA 
makes the necessary changes and re-submits the assessment.  The correction number 
for this assessment is reset to 00. 
 
2202.11D - Documentation of Corrected Assessments 
(Rev. 1, 05-21-04) 
 
When a comprehensive assessment is corrected, the HHA must maintain the original 
assessment record as well as all subsequent corrected assessments in the patients clinical 
record in accordance with current clinical record requirements at 42 CFR 484.  If 
maintained electronically, the HHA must be capable of retrieving and reproducing a hard 
copy of these assessments upon request.  It is acceptable to have multiple corrected 
assessments for an OASIS assessment, as long as the OASIS and the clinical record are 
documented in accordance with the clinical record requirements at 42 CFR 484. 
  2202.11E - Clinical Implications of Corrected Assessment Records 
(Rev. 1, 05-21-04) 
 
When corrections are made to an assessment already submitted to the OASIS State 
System, the HHA must determine if there is an impact on the patients current care plan.  
If there is an impact, in addition to the correction made to the assessment, the HHA must 
make corresponding changes to the current care plan.  If there are any other records where 
the correction has an impact, for example, the Home Health Resource Group, the Plan of 
Treatment (CMS Form-485), or the Request for Anticipated Payment, the agency should 
make corresponding changes to that record, as applicable.  The agency should establish a 
procedure to review the impact of any corrections made to assessment records and make 
corresponding changes to other records that are affected. 
 
2202.11F - Regarding Corrections in Lieu of Required Assessments 
(Rev. 1, 05-21-04) 
 
Collection and submission of information on SOC, ROC, Follow-up, Other Follow-up, 
transfer, and discharge assessments are required by the comprehensive assessment 
requirements at 42 CFR 484.  The correction process described here does not preclude the 
need for accurate patient assessment at the required time points. 
 
The inactivation of an assessment and subsequent correction and re-submission of a new 
assessment, or a correction to a non-key field cannot be used in lieu of the appropriate 
OASIS assessment for documenting an unanticipated change in patient condition that was 
not envisioned in the original plan of care.  If there is an unexpected change in the 
patients clinical condition due to a major decline or improvement in health status that 
warrants a change in plan of treatment, the appropriate OASIS assessment is expected to 
document the change, i.e., the ROC or Other Follow-up assessment, as appropriate. This is 
in keeping with the regulation at 42 CFR 484.20(b) for accuracy of encoded OASIS data 
that states, The encoded OASIS data must accurately reflect the patients status at the 
time of assessment.  The HHA should have one document for the patients assessment, 
care planning, and payment purposes. 
 
2202.11G - Timeliness of Corrections 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
HHAs are urged to make corrections and/or submit inactivations as quickly as possible 
after errors are identified so the state system will be as current and accurate as possible 
prior to HHA submission of the RAP.  This also affects the data used to calculate the 
HHAs OBQI and OBQM reports. 
 
2202.11H - Multiple Corrections in a Record 
(Rev. 1, 05-21-04) 
 
Correcting assessments with key field errors can only be done by inactivating the incorrect 
assessments and replacing them with the corrected assessments, as previously described 
above.  Correcting assessments with non-key field errors can only be done by re-opening  the assessment, revising the targeted non-key fields, re-locking and re-submitting the 
assessment, as previously described above. CORRECTION_NUM (the counter field) is 
implemented in non-key field changes.  For more specific information concerning the 
process of correction and inactivation, refer to the OASIS data specification notes on the 
OASIS web site. 
 
See below for a flow chart depicting the most common situations necessitating corrections 
 
2202.12 - OASIS State System 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The purpose of the OASIS State System is to provide computerized storage, access, and 
analysis of the OASIS data on patients in HHAs across the nation.  The OASIS State 
System is intended to create a standard, nationwide system for connecting HHAs to their 
respective SAs for the purpose of electronic interchange of data, reports, and other 
information.  The automated OASIS system is a critical component of SA and CMS 
operations.  It is a key part of a fully integrated system of clinical data, facility 
demographics, survey findings, and SA operations information.  The OASIS State System 
also provides the means for transmission of assessment data to CMS for validating 
payments under prospective payment for HHAs.  
 
The OASIS State System implementation involved a CMS-funded installation of 
standardized computer hardware and data management software at each SA to allow 
electronic transfer of OASIS data elements from all HHAs to the State.  The data 
management software: 
 
Validates the basic accuracy of the data and rejects submission files (batches) with fatal 
file errors, such as a missing or invalid agency ID, incorrect record length, or missing 
headers or trailers;  
 
Validates individual assessment records and rejects those records with fatal record errors; 
 
Stores and reports non-fatal or warning errors on records that are accepted by the database; 
and 
 
Builds a database of OASIS information for all applicable patients of each HHA in the 
State. 
 
In accordance with the regulations, HHAs will collect SOC, ROC, follow-up, discharge to 
the community, transfer to an inpatient facility (with or without discharge), and death at 
home OASIS data on all patients (except those under 18; those receiving maternity 
services; and patients receiving only housekeeping or chore services) under the care of the 
HHA as of July 19, 1999, as applicable.  The requirements for OASIS collection, 
encoding, and transmission apply to all Medicare and Medicaid patients, including 
Medicare and Medicaid HMO/Managed Care patients (with the exception of those listed 
above) receiving skilled services.  The applicability of the comprehensive assessment and 
reporting regulations to patients receiving personal care only services, regardless of payer  source, has been delayed until further notice.  In addition, the collection, encoding and 
transmission requirement for non-Medicare and non-Medicaid patients receiving skilled 
care is also temporarily suspended until further notice.  Until collection and submission of 
non-Medicare/non-Medicaid patient assessments is required, HHAs must meet all other 
requirements of the comprehensive assessment regulation including conducting SOC 
comprehensive assessments and updates at the required time points on all non-Medicare 
and non-Medicaid patients receiving skilled services, although the OASIS data items are 
not required.  This means that only the requirement to collect, encode and transmit OASIS 
data is delayed.  The completion of the comprehensive assessment and updates at the 
required time points is required in order to ensure quality of care for all patients and to 
encourage the use of OASIS as the basis for care planning. 
 
Effective August 24, 1999, and at least monthly thereafter, HHAs should transmit to the 
SA all applicable OASIS data collected and encoded from July 19, 1999, and monthly 
thereafter.  Monthly transmissions should include all OASIS data encoded in the previous 
month.  
 
OASIS activities will provide enhanced analytical capabilities at the SAs; electronic 
transmission from the State databases to a national repository; integration with 
performance indicators for quality oversight and survey planning by the SA; a basis for 
maintaining prospective payment of HHAs; research directed at improving quality of care; 
feedback to providers; and dissemination of information to purchasers, beneficiaries, and 
others. 
 
2202.12A - System Description 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The CMS has provided each State with an OASIS State System composed of standardized 
hardware and software platforms scaled to meet each States anticipated processing 
volumes, and a standardized operating system.  The hardware is comprised of a 
communications server, database server, the local area network, and other peripheral 
devices. 
 
The OASIS State System deployed to each State was specifically engineered and 
purchased to fulfill the OASIS requirements of 484 and 488, as well as to incorporate 
additional CMS provider assessment processes as they become effective, and operational 
support of Medicare and Medicaid Survey and Certification pursuant to 1864 of the Act.  
The system was designed with an emphasis on flexibility and integration, so that 
additional software components could be easily added to provide the States with new 
related functionality (such as outcome measures and expanded analytical reports), as well 
as applications that support future assessment processes for other provider types, and new 
capabilities to support survey and certification operations.  Since each States OASIS 
system was specifically sized to accommodate these planned functions, the SA should not 
add other non-CMS prescribed applications or databases to it. 
 
2202.12B - Administration Requirements 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14)   
The OASIS State System in each State is part of a comprehensive, Quality Improvement 
and Evaluation System that will not only fulfill OASIS administration requirements, but 
also grow to support other assessment-based programs; quality and performance 
indicators; and new, integrated survey and certification data systems.  The State should 
use the OASIS State System for editing, storing, and processing OASIS data to support 
CMS OASIS operating requirements within the State and to transmit the required OASIS 
data to the CMS OASIS repository.  As noted above, the State may not add additional 
software applications to the OASIS system without a specific directive from CMS. 
 
The States are directly responsible for fulfilling requirements to operate the OASIS State 
System.  However, the State may enter into an agreement with the State Medicaid agency, 
another State component, or a private contractor to perform day-to-day operations of the 
system.  
 
The State must obtain RO approval prior to entering into an agreement with another 
agency. Such agreements should address the following provisions: 
 
1.  Meets confidentiality requirements:  Federal Privacy Act, 5 U.S.C. 522a; HIAA 
of 1996; other applicable Federal data acts; 1902(a)(7) of the Act; applicable 
State standards; and industry security standards; 
 
2.  Gives the SA real-time access to the system to fully support all OASIS-driven 
functions which will be required of the survey agency (e.g., quality indicator 
reporting, survey targeting, etc.), or if a contractor is performing analysis for SA 
contract, provides the details on how this is to be conducted; 
 
3.  Complies with the need for high capacity, fault-tolerant network connections to 
ensure reliable support for the SAs, CMS national database, and any other daily 
operations (e.g. Intermediary Medical Case Review, Office of the Inspector 
General or Department of Justice Fraud and Abuse activities), which will be 
affected by this system.  Assures hardware will be properly maintained and 
upgraded as necessary to meet any future CMS or SA requirements.  Assures 
adequate backup of all data; 
 
4.  Includes SA responsibilities for reporting OASIS data to a central repository at 
CMS. Designates responsibilities for edits and cleanness of data: 
 
 Designates responsibilities for generating and communicating facility error 
reports.  
 
 Describes what kinds of communication will be established, e.g., a State-specific 
Internet and/or Intranet web pages, newsletters, etc., their content, and who 
will produce/maintain/distribute these communications.  
 
If there is a separate database, designates who is responsible for operating and 
maintaining the CMS-provided equipment and who will assure the viability of the  CMS database;  
 
5.  Lists responsibilities of contractor and/or State for training and support operations:  
Includes at least who will provide facility and OASIS software vendor startup 
training, and on-going customer/facility support/troubleshooting; provide internal 
training and daily user support within the SA; work with program staff to integrate 
the OASIS system into SA functions; train SA staff on aspects of analytical system 
(e.g., ASPEN upgrades and performance measure/quality indicator linked 
reports); handle System Operations - functions associated with transmission 
logging, error tracking and resolution, system archival, and process reporting; and 
designate who is responsible for determining facility transmission schedules; 
 
6.  Delineates how State will fund the monthly line charges associated with 
installation, maintenance, and transmission of the OASIS data from the facilities to 
the contractor and between the contractor and State, e.g., built into contract costs 
or is an outside ongoing cost to the SA; and 
 
7.  Specifies whether it is the contractors or the SAs responsibility for systems 
maintenance for commercial off-the-shelf OASIS hardware and software 
components. 
 
NOTE: Standardized OASIS software components that are developed and distributed by 
CMS will be maintained and upgraded centrally by CMS.  
 
Under any such arrangement, the State must be guaranteed real-time, priority access to 
this system to fully support all OASIS functions. All CMS privacy and confidentiality 
requirements must be met.  Off-site operation of the OASIS State System will require high 
capacity, fault-tolerant network connections to ensure reliable support for the States daily 
operations that will be affected by this system.  The State also must use the OASIS State 
System for reporting OASIS data to the CMS central repository.  
 
To promote national consistency in OASIS system operations and troubleshooting, each 
State should designate one individual as the OASIS automation project coordinator.  This 
person is CMS key contact within each State for managing OASIS State System issues 
and must be familiar with the use of the OASIS automation and transmission process.  
Technical knowledge of information systems is useful but far less critical than an 
understanding of the OASIS processes, good communication and project management 
skills, and the ability to educate and work with providers and vendors to ensure successful 
implementation of an automated process for all providers.  The State should designate 
additional staff, including a System Administrator, to manage the technical aspects of 
running the OASIS State System and support staff to assist in processing corrections, 
answering routine user questions, assigning passwords, etc. 
 
With respect to systems maintenance, the OASIS State System installed in each State is 
comprised of commercial, off-the-shelf hardware, and software components that are 
generally covered under typical umbrella service agreements that the State may already 
have in place for maintenance of data processing equipment.  Those OASIS software  components that are developed and distributed by CMS will be maintained and upgraded 
centrally by CMS.  The State will not be responsible for these software upgrades. 
 
To the extent that the State has developed customized external applications for using 
information obtained from the OASIS database (e.g., to support Medicaid payment), the 
costs of developing and maintaining these additional software applications (and any 
related hardware components) will not be funded through the survey and certification 
budget. 
 
2202.12C - Validation and Editing Process 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Each time an HHA accesses the OASIS State System and transmits an assessment file, it 
performs a series of three levels of validations: 
 
1.  Fatal File Errors 
 
  The first check examines the basic structure and integrity of the submission file.  
If there are fatal flaws in the file (batch of records), then the entire file is 
rejected and the HHA is notified of the reason for rejection in the Initial 
Feedback Report.  In the event that a batch is rejected due to fatal file errors, 
the HHA will not receive a Final Validation Report.  Fatal file errors are 
listed in the data specifications, which can be found on the OASIS Web site.  
Rejected files must be corrected and retransmitted. 
2.  Fatal Record Errors 
 
  If the file structure is acceptable, then each record in the file is examined 
individually for fatal record errors.  These errors may cause an individual 
assessment within a submission to be rejected.  Assessments that have fatal 
records are not stored in the database.  The HHA is informed of fatal record 
errors on the Final Validation Report.  OASIS data specifications outline the 
valid data requirements and are posted on the OASIS Web site. 
 
The Initial Feedback and Final Validation reports are available shortly following 
the submission of a file. 
 
3.  Non-Fatal or Warning Errors 
 
If there are no fatal record errors, the record is loaded into the State database and 
the record is further examined for non-fatal errors.  Any non-fatal errors are 
reported to the facility in the Final Validation Report.  Non-fatal errors include 
missing or questionable data of a non-critical nature, record sequencing, field 
consistency errors, invalid value, and range errors. 
 
The Initial Feedback Report is available immediately following the submission of a file.   The HHA should obtain this report before logging off to ensure the submission has been 
processed.  Since the Final Validation Report is not available for up to 48 hours after the 
Initial Feedback Report, the HHA may, based on experience, choose to obtain this report 
on a subsequent log on. 
 
The validations and edits described above fulfill all of CMS editing requirements under 
488.68.  Also, States may not modify any aspect of the CMS OASIS standard system, 
including these validations and edits, the Standard Record Layout, and the software code 
and specifications on which the system is based. 
 
States that use OASIS data for Medicaid payment may require additional assessment 
information not required by CMS OASIS system.  Some States may impose additional 
edits on Medicaid assessments.  However, a State may not interfere with, modify, or delay 
the transmission of records meeting CMS edit standards from a Medicare-certified or 
Medicaid-approved agency to the CMS OASIS standard system.  Furthermore, the State 
may not impose any requirements that modify the clinical accuracy of CMS prescribed 
OASIS records, reports, or calculations. 
 
2202.12D - Reports 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OASIS State System provides reports to both the State and the provider.  These 
reports, which focus on errors in OASIS submissions, are particularly key to working with 
agencies to ensure successful transmission of OASIS data.  Refer to the State OASIS 
Administration Manual available on the QTSO Web site (http://www.qtso.com/) for 
information about specific reports provided.  Monthly validation of OASIS submission is 
highly recommended for both states and providers as OASIS is required for payment, pay 
for reporting, and medical review. 
 
2202.12E - Replication to the CMS Repository 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
Each States OASIS database will be transmitted to the CMS central repository at least 
monthly using a data replication process initiated by CMS.  Since the process will be 
managed by CMS through an automatic polling process, the States will not actually have 
to transmit the data.  However, the State must ensure that the CMS data line established 
for this purpose is accessible to CMS at all times for testing and monitoring purposes.  
Actual access to the Oracle assessment data tables may be controlled by the States but in 
such cases, CMS recommends that a fixed schedule be established with CMS central 
office. 
 
The OASIS State System and CMS data line meet all industry security standards.  
However, if the State is concerned about security, it may establish a firewall (an electronic 
block) to restrict access to the States portion of the network.  Access must not be 
restricted to the CMS-supplied OASIS System. 
  2202.12F - System Security 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
As distinguished from confidentiality and privacy, which primarily focuses on the rules 
for release of information when it is authorized, security relates to the means by which the 
information is protected from unauthorized access, disclosure, and misuse.  As part of 
the new requirements under 488.68, States must ensure that electronic data in the OASIS 
State System are protected to the same degree that paper records containing any 
identifiable data must be safeguarded.  Additionally, any printed copies of reports from the 
system must be maintained in a secure locked area while they are needed and properly 
disposed of when no longer needed.  States must issue a policy that defines and limits the 
qualifications for an individual to access the OASIS State System.  The System 
Administrator must issue passwords and user identifications in strict adherence to those 
requirements.  State personnel who receive passwords must be aware of the requirements 
of the States security policies and those of the System of Records and the Privacy Act.  
Passwords must be protected by the System Administrator and those receiving passwords.  
Passwords must be disabled at the time an individual exits a position requiring OASIS 
State System access.  SAs are likewise reminded of the secure nature of passwords for the 
HHAs and must use due process to ensure the security of those passwords. 
 
State personnel should not leave the OASIS State System in a logged-in status when 
leaving the area.  If possible, the system hardware should be located in an enclosed area, 
preferably with a door having interior hinges that can be locked.  Keys or a combination 
lock should be available to only a minimum group of individuals with need for access to 
the system.  
 
In addition to the specific guidance above, the safeguards must provide a level of security 
at least equivalent to that required by the Office of Management and Budget Circular A-
130 (revised), Appendix III, Security of Federal Automated Information Resources. 
 
2202.12G - Security of Transmission 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OASIS data is encoded and transmitted from HHAs to SAs via the CMSnet, a private 
communications network CMS purchased to ensure the security of OASIS and MDS 
transmissions to the State.  This system replaces the previous process of direct dial-up by 
public telephone lines to the SA and reflects the latest technology available for securing 
the privacy of data during transmission.  Standard industry authentication is employed at 
each SA.  Further security is provided at the SA by isolation of the receiving 
communications server from the actual storage site at the State (the MDS/OASIS 
Database Server).  This serves effectively as a security firewall.  Transmission of OASIS 
data from the SAs to CMS occurs via the CMS Virtual Private Network (VPN), which 
allows only authorized CMS staff access within this secure CMS infrastructure. 
 
The CMS has determined that the transmission of OASIS data through the process 
described above is fully compliant with all current Federal, Department of Health and 
Human Services, and CMS information systems security requirements.  The applicable  Federal guidelines include The Computer Security Act of 1987, Federal Information 
Processing Standards promulgated by the National Institute of Standards and Technology 
pursuant to the Computer Security Act of 1987, the Office of Management and Budget 
Circular A-130 (revised), and Appendix III, Security of Federal Automated Information 
Resources. 
 
Per CMS policy, in the CMS Information Systems Security Policy, Standards and 
Guidelines Handbook, it is a violation of the CMS Security policy to send via email or 
fax: patient personally identifiable information, IP addresses, and both ID and password in 
the same document.  CMS Security policy prohibits saving the login information in the 
Internet browser or sharing the personal login ID or the password with anyone else. 
 
2202.12H - Provider Relations 
(Rev. 1, 05-21-04) 
 
With CMS technical support and guidance, the States work closely with the provider 
community and their OASIS software vendors in providing information on specific 
requirements related to the submission of OASIS assessments to the OASIS State System.   
 
The CMS expects that some vendors will provide primary support to HHAs in terms of 
OASIS encoding and transmission to the State repository.  The State, however, must work 
with HHAs and software vendors in educating them about this process.  The States must 
also provide training and technical assistance in interpretation of OASIS reports provided 
to HHAs.  
 
2202.13 - Protection of the Confidentiality of OASIS Data 
(Rev. 1, 05-21-04) 
 
2202.13A - OASIS System of Records 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OASIS database is operated and maintained by States or CMS contractors as a 
Federal database and, as such, is subject to the requirements of the Federal Privacy Act.  
In general, the only records subject to the Privacy Act are records that are maintained in a 
system of records (SOR).  The idea of a system of records is unique to the Privacy Act 
and requires explanation.   
 
The Act defines a record to include most personal information maintained by an agency 
about an individual.  A record contains individually identifiable information, including but 
not limited to information about education, financial transactions, medical history, 
criminal history, or employment history.  A SOR is a group of records from which 
information is actually retrieved by name, social security number, or other identifying 
symbol assigned to an individual. 
 
The text of the SOR notice for the OASIS database describes the legal requirements 
regarding privacy and disclosure of information by CMS or the State.  The assigned 
identifying number for this system is: System No. 09-70-0522.    
The CMS established a new SOR, published June 18, 1999, in the Federal Register (64 
FR 32992) containing data on the physical, mental, functional, and psychosocial status of 
patients receiving the services of HHAs that are approved to participate in the Medicare 
and/or Medicaid programs.  The purpose of the system is to aid in the administration of 
the survey and certification of Medicare/Medicaid HHAs and to study the effectiveness 
and quality of care given by those agencies.  This system also supports regulatory, 
reimbursement, policy, and research functions, and enables CMS to provide HHAs with 
outcome data for providers internal quality improvement activities.   
 
The OASIS SOR was modified and published on December 27, 2001, (66 FR 66903) to 
allow a new routine use authorizing disclosure to national accrediting organizations that 
have been approved by CMS for deeming authority for Medicare requirements for home 
health services.  This SOR notice replaces the SOR notice published June 18, 1999.  The 
SOR was again updated November 13, 2007. 
 
The HHA SOR contains individually identifiable clinical assessment information (OASIS 
records) for all Medicare/Medicaid patients receiving the services of a Medicare and/or 
Medicaid approved HHA, except prepartum and postpartum patients; patients under 18 
years of age;  patients receiving only housekeeping services and/or chore services 
exclusively; and, until sometime in the future, patients receiving only personal care 
services. The CMS established the system in accordance with the principles and 
requirements of the Privacy Act. 
 
2202.13B - Protection of Confidentiality Under the Privacy Act of 1974 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OASIS data are generally protected under the provisions of the Privacy Act of 1974.  The 
Privacy Act of 1974 protects the confidentiality of person-specific records that are 
maintained by the Federal Government and retrieved by a unique indicator.  It contains 12 
conditions of disclosure under which these records may be released without the written 
consent of the individual. 
 
The system notice for the OASIS repository (HHA OASIS) was originally published in 
the Federal Register on June 18, 1999, and modified on December 27, 2001 and 
November 13, 2007.  The system notice contains a listing of the prescribed limited 
circumstances under which person-specific records contained in that system may be 
released.  These circumstances are called routine uses.  Routine uses must be compatible 
with the purpose for which the records are collected and maintained.  The OASIS system 
notice now contains nine routine uses. 
 
Requests submitted to CMS for release of OASIS data are forwarded to the appropriate 
data release authority.  The authority to release data from the OASIS national repository 
is limited to the System Manager and his or her designees.  The OASIS System Manager 
is the Director of the Survey and Certification Group at CMS, and as such has the sole 
authority to grant or deny a request for access to, or disclosure of data contained in the 
HHA OASIS system of records.  It is the responsibility of the data release authority to  review these requests for adherence to Privacy Act requirements.  Release of data from 
any system is discretionary. 
 
Release of data from the OASIS repository follows CMS policy and procedure for data 
release.  It is CMS policy that each requestor of Privacy Act protected data must sign a 
CMS approved Data Use Agreement (DUA).  A DUA is not required by the Privacy Act, 
however; it is one safeguard CMS has instituted in order to protect the confidentiality of 
identifiable data.  DUAs are an integral part of the data use approval process.  The 
agreements delineate the confidentiality requirements of the Privacy Act and CMS data 
use policies.  The agreement serves as both a means of informing data users of these 
requirements and a means of obtaining their agreement to abide by these requirements.  
Additionally, the agreements serve as a control mechanism through which CMS can track 
the location of its data and the reason for the release of the data.  CMS Office of 
Information Systems carries the functional responsibility to control guidelines and policies 
for the language in the agreements and coordinates the requests for release of data. 
 
2202.14 - SA and RO Roles and Responsibilities 
(Rev. 1, 05-21-04) 
 
2202.14A - State 
(Rev. 1, 05-21-04) 
 
The CMS expects the SA to play a key role in providing the educational and technical 
resources to HHAs in each State concerning OASIS.  States must designate an OASIS 
Automation Coordinator and OASIS Educational Coordinator to function as resources for 
the HHAs in each State.  These positions are funded by CMS through the Medicare 
Survey and Certification program. 
 
Each State Automation Coordinator must have the ability, through education, training, or 
experience, to provide for the statewide administration of the OASIS project.  The State 
Automation Coordinator provides systems operations and technical support for the HHAs, 
vendors, and SA staff.  The State OASIS Educational Coordinator must be a member of 
any professional discipline operating in the home health environment, that is, a social 
worker, registered nurse, occupational therapist, or physical therapist.  Together, the 
functions of these two positions include providing training and educational support to 
HHAs in the administration of OASIS for: 
 
  Integrating the OASIS items into the HHA assessment process; 
 
  Answering questions on the clinical aspects of OASIS; 
 
  Training HHAs on the OASIS data set administration; 
 
  Providing information about hardware and software requirements for HHAs to 
consider when automating OASIS; 
 
  Training HHAs on submission of OASIS data to the State and interpreting  validation reports, including providing support for transmission of test data during 
start-up, supporting callers requesting technical assistance, providing passwords to 
HHAs, and answering questions about computer edits and reports; 
 
  Submit an annual training report of the state-wide OASIS training and other 
activities in the Home Health Training Worksheet available in Casper reports of 
the QIES system by October 15 following each Federal Fiscal Year. 
 
  Using the outcome reports generated by the OASIS data; 
 
  Using OASIS data in survey tasks; 
 
  Training other SA staff, as applicable;  
 
  Providing information from OASIS to determine prospective payment rates for 
HHA patients; and 
 
  Participating in training updates on OASIS and related home health issues. 
 
2202.14B - Regional Office 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
ROs also have OASIS coordinators for the implementation updates and automation of 
OASIS.  Designated RO staff provides information about OASIS in the region, act as a 
resource to the provider and a consultant to the SA.  They also administer survey and 
certification funds, and other aspects of the OASIS project.  At least one RO staff person, 
knowledgeable about home health survey and certification issues, and/or knowledgeable 
about MDS automation coordination should be assigned to these OASIS related roles.  
ROs must provide the States with the program guidance and technical assistance critical to 
the successful implementation of OASIS and ensure that the States have the necessary 
resources to accomplish these goals. 
 
The following activities are performed by the RO: 
 
1.  Budget Process 
 
The RO reviews each SAs budget request and the required OASIS 
Implementation Plans in accordance with the SCG Budget instructions.  The RO 
must monitor for a reasonable and prudent expenditure of funds to ensure that 
States receive a fair and reasonable allocation.  The RO must monitor Quarterly 
Expenditure Reports against the States allocation. 
 
2.  Review State Implementation Plans 
 
The RO annually reviews all State OASIS Implementation Plans to ensure States 
have reasonable plans for assisting HHAs with the technical information, training, 
and assistance needed to comply with requirements for OASIS submission,  accuracy, privacy, and security. The RO must assess whether States are monitoring 
HHA compliance with the OASIS requirements. 
 
3.  Review Contracts and Agreements 
 
The RO ensures that the SA has executed an agreement with any other entity if that 
other entity is operating the OASIS system on behalf of the SA.  The RO must use 
the criteria in 2202.12.B in performing this review. 
 
4.  Provide Training and Technical Assistance 
 
The RO supports CO in training and technical assistance to the States in OASIS 
and ASPEN requirements and supports OASIS continuing education and program 
requirements. 
 
5. Perform Focused Reviews/Federal Surveys 
 
The RO uses the OASIS Repository and outcome data to select HHAs for focused 
reviews, and in preparation for Federal surveys. 
 
6.  Take Enforcement Action. 
 
The RO processes and carries out enforcement actions for non-compliance with 
OASIS requirements (as reported by SAs). 
 
2202.15 - OASIS Education and Training 
(Rev. 1, 05-21-04) 
 
2202.15A - State 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The OASIS Educational and Automation Coordinators (OEC/OAC) participate in various 
training programs concerning OASIS, monthly All State teleconferences to discuss OASIS 
issues, and meetings for OASIS updates and other matters related to home health services, 
as necessary.  State support is provided by CMS central office, ROs, the OASIS Web site, 
and clinical and technical Help Desks supported by CMS contractors. The State OACs and 
OECs are considered the subject matter experts who provide training to State Agency staff 
and act as a resource to providers.  
 
The OASIS Education Coordinators (by state) can be found at:- 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/OASIS/EducationCoord.html. 
  
The OASIS Automation Coordinators (by state) can be found at: - 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/OASIS/AutomationCoord.html. 
  2202.15B - RO 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The RO OASIS Coordinators participate in regularly scheduled teleconferences with 
central office to discuss issues concerning updates and maintaining OASIS and other 
related survey issues.  RO staff participates in periodic meetings for OASIS updates and 
other matters related to home health services as scheduled. 
 
2202.15C - HHAs 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
All HHAs, both existing and prospective, are trained on the implementation and 
automation of OASIS by each States OASIS Educational and Automation Coordinators.  
HHAs with clinical, technical and regulations-related questions should contact the State 
OASIS Educational or Automation Coordinator about OASIS.  A current list of the State 
OASIS Educational Coordinators is found on the OASIS Web site.  Support is also 
available for HHAs via the OASIS Help Desk. The Help Desk can be accessed toll-free by 
telephone on (877) 201-4721 between the hours of 7:00 a.m. and 7:00 p.m. Central Time 
and by electronic mail at HAVEN_help@IMFC.org. 
 
The SA provides support to HHAs by providing OASIS presentations at meetings 
sponsored by the SA, HHA provider associations, or other entities. 
 
Updates to existing software and training manuals which support OASIS updates, 
HAVEN, and the OASIS State System, are distributed via the OASIS and QTSO Web 
site. 
 
2202.16 - Fax Transmission of OASIS or Other Patient Identifiable 
Information 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
OASIS assessment data is personal information about home health recipients that HHAs 
are required to collect and keep confidential in accordance with federal law.  The use of 
electronic means of communication is acceptable in HHAs, if appropriate safeguards are 
in place. The fax machine provides a fast and inexpensive method to send and receive 
patient specific information, such as patient referrals and physician orders.  However, the 
use of fax transmission can open up the possibility that confidential patient information 
can be transmitted or handled in a manner that is not secure and does not protect the 
patients confidential health information.  For example, the use of an incorrect fax number 
can allow the material being transmitted to persons who are not legally authorized to have 
this information.  CMS takes its responsibility seriously to protect patient specific 
information once it has been transmitted to the State, and CMS expects HHAs to provide 
the same protections to OASIS data while it is maintained at the HHA. 
 
SAs must follow Federal requirements for systems that retain Federal data e.g., MDS data, 
OASIS data.  Additional information on information security (IS) can be found on the CMS 
Information Security web pages at http://www.cms.gov/Research-Statistics-Data-and- Systems/CMS-Information-
Technology/InformationSecurity/index.html?redirect=/informationsecurity in the CMS Policy 
for the Information Security Program (PISP) and the CMS IS Acceptable Risk Safeguards 
(ARS) found under Policies and Standards. 
 
The home health CoP at 484.11, Release of Patient Identifiable OASIS information, 
requires that HHAs and agents acting on behalf of the HHA in accordance with a written 
contract must ensure the confidentiality of all patient identifiable information contained in 
the clinical record, including OASIS data, and may not release patient identifiable 
information to the public. 
 
It is the responsibility of the HHA to make sure that it has a written contract providing its 
agent with the legal authority to encode and transmit OASIS assessment data.  The 
contract should also ensure that the agent holds all OASIS data confidential.  Each HHA 
that uses fax transmission of OASIS information should develop its own policies and 
procedures to assure confidentiality of patient information, as well as, comply with legal, 
regulatory and accreditation requirements.  It is also the responsibility of the HHA to 
make sure that OASIS assessment data is transmitted to its agent by a secure method. 
 
If the HHA chooses to use facsimile transmission of OASIS data, guidelines for use of 
facsimile transmission of OASIS data are provided below: 
 
  The HHA or agent should place fax machines in a secure area and limit access to 
them. 
 
  The HHA should identify one person in a department or unit to monitor incoming 
documents on a fax machine, or to deliver the document information directly into a 
secured data base system. 
 
  The HHA should outline appropriate written policies that safeguard that 
transmitted OASIS information is sent to the appropriate person and verify the 
correct facsimile number to which the OASIS data is being transmitted.  This 
should include:  
 
(a) Use of the of a cover sheet, either electronic or hard copy, accompanying 
the faxed information that specifies that the OASIS information is 
confidential and limits its use to the terms of the written contract; 
 
(b) That the person who is the legal authority for the receipt of the OASIS 
information is prohibited from disclosing this information to any other 
party, any may use the data only for the purposes outlined in the written 
contract; and  
 
(c) The HHA should contact the agent to verify the correct fax number to use 
prior to faxing. 
 
The HHA should develop and enforce procedures to be followed in the case of a  misdirected transmission. This should include: 
 
(a) A notice on the cover sheet that prohibits the disclosure, copying, or distribution of 
the information by the unintentional receiver of the fax; 
 
(b) A notice to the unintentional receiver of the fax to notify the sender immediately if 
they have received this information in error to arrange for the return of the 
information; and  
(c) The name and phone number of the sender to contact.   
 
HHAs shall only use or disclose patient identifiable records as permitted or required by 
law. 
 
State survey agencies should follow the CMS guidelines when sending and receiving 
requests to correct errors to the OASIS data base. 
 
2202.17 - Change of Ownership, Merger, and Termination Procedures 
Affecting HHAs and OASIS Requirements 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
It is imperative that the Medicare CCN be accurately reported on the OASIS assessments 
in all reports, including when HHAs undergo change of ownership, merger, or 
termination.  
 
Change of Ownership - Mergers 
 
In accordance with 489.18 and 3210, the merger of a provider corporation into another 
corporation constitutes a change of ownership.  In the case of the merger of Agency A into 
Agency B, Agency As provider agreement and its associated CCN are terminated.  
Agency B retains its existing provider agreement and CCN.  Agency A should provide the 
OASIS discharge comprehensive assessment for each discharged patient prior to or at the 
effective date of the merger.  The surviving HHA (Agency B) should provide a Start of 
Care (SOC) comprehensive assessment for all persons it admits after the merger at the 
next skilled visit after the official merger date. The SOC assessment will allow eligibility 
for the home health benefit to be verified and care planning for the individual to proceed 
under Agency B.  Subsequently, the assessments for all individuals being accepted for 
care by Agency B will be linked to the correct provider number to enable the agency to 
engage in quality improvement efforts with accurate OBQI reports. 
 
In accordance with 489.18 and 3210, when there is a permissible change in ownership 
under 424.550(b)(2), as described below and the new owner does not reject automatic 
assignment of the existing provider agreement under 489.18(c), the new owner is subject 
to all the terms and conditions under which the existing agreement was issued, including 
compliance with the comprehensive assessment of patients condition of participation.  The 
CCN remains the same if the new HHA owner accepts assignment of the existing provider 
agreement.  The new owner is responsible for continuing to complete updates to the 
comprehensive assessment at the next scheduled time points.   
Change of Ownership without Assignment 
 
In accordance with 489.18 and 3210, when there is change of ownership and the new 
owner rejects this automatic assignment of the provider agreement, the provider 
agreement and provider number of the former owner should be terminated.   
 
The HHA that is terminating its provider agreement and provider number should provide 
an OASIS discharge comprehensive assessment for each patient subject to OASIS 
standards prior to the effective date of the termination, according to 484.  The new HHA 
will not be able to participate in the Medicare program without going through the same 
process as any new provider, which includes an initial survey. The HHA should meet all 
the Federal requirements, including applicable OASIS requirements as specified in the 
regulations, for all persons it accepts for care in order to participate in the Medicare 
program.  This means that the HHA should provide a new SOC comprehensive 
assessment at the first skilled visit once it becomes Medicare-approved.  In addition, 
updates to the comprehensive assessment should be provided at the other OASIS time 
points, in accordance with 484, for all patients of the former owner it accepts for care. 
 
NOTE:  The Medicare Program; Home Health Prospective Payment System Rate Update 
for Calendar Year 2011; Changes in Certification Requirements for Home Health 
Agencies and Hospices; Final Rule(75 FR 70372) (also referred to as CMS-1510-F) 
published on November 17, 2010, revised certain policies related to the prohibition of the 
sale or the transfer of HHA billing privileges at 424.550(b)(1), defined change in 
majority ownership at 424.502, and provided several exceptions to the new 36-month 
rule.  Specifically, the final rule provided that, effective January 1, 2011, and in 
accordance with 424.550(b)(1), if there is a change in majority ownership of an HHA by 
sale (including asset sales, stock transfers, mergers, and consolidations) within 36 months 
after the effective date of the HHAs initial enrollment in Medicare or within 36 months 
after the HHAs most recent change in majority ownership, the provider agreement and 
Medicare billing privileges do not convey to the new owner. 
 
Section 424.502 defines the term Change in Majority Ownership as a transaction in 
which an individual or organization acquires more than a 50 percent direct ownership 
interest in an HHA during the 36 months following the HHA's initial enrollment into the 
Medicare program or the 36 months following the HHA's most recent change in majority 
ownership (including asset sales, stock transfers, mergers, and consolidations).  This 
includes an individual or organization that acquires majority ownership in an HHA 
through the cumulative effect of asset sales, stock transfers, consolidations, or mergers 
during the 36-month period after Medicare billing privileges are conveyed or the 36-
month period following the HHA's most recent change in majority ownership. 
 
If the CMS RO or SA receives an inquiry from the provider regarding procedures for a 
change in majority ownership pursuant to 424.550(b) (1), it should refer the provider to 
its Medicare Administrative Contractor (MAC).  The MAC will review the applicable 
time frames, exceptions and any other pertinent enrollment requirements, and will 
determine if the facility has had a majority ownership change within 36 months of its  initial certification or within 36 months of another majority ownership change.   
 
If the proposed HHA change of ownership meets the revised HHA change in majority 
ownership definition, it must: 
 
  Enroll in the Medicare program as a new (initial) HHA under the provisions of 
424.510; 
  Obtain a State survey or an accreditation from an approved accreditation 
organization with deeming authority; and 
  Sign a new Medicare provider agreement and receive a newly assigned CMS 
Certification Number (CCN). 
 
CMS will deactivate the HHAs old Medicare billing number if the sale has already 
occurred.  
 
Scheduling of an initial certification survey is initiated by a recommendation from the 
MAC to the RO/SA.  The SAs and ROs will follow the current established processes and 
policies for initial certification.  The initial surveys required under the change in majority 
ownership guidelines will be considered Tier IV as per CMSs Mission Priority Document 
(MPD).  The HHA may utilize an approved AO for an initial survey if it is seeking 
deemed status through accreditation.  It is the responsibility of the HHA to arrange the 
initial Medicare survey with the AO. 
 
Upon successful completion of the enrollment and survey process, the new HHA will have 
a new effective date of Medicare participation and a new CCN. 
 
Questions from the provider community about the definitions for a change in majority 
ownership and specifics regarding participation dates, exceptions, etc., should be directed 
to the applicable MAC. 
 
An existing HHA that has engaged in a transaction that meets the definition of change in 
majority ownership is considered to have voluntarily terminated its participation under its 
original provider agreement.  The requirements for a provider/supplier to terminate 
voluntarily from participation in the Medicare program are set forth at 489.52.  The RO 
should follow the usual procedure regarding voluntary termination, using the date of the 
ownership change as determined by the MAC as the effective date of voluntary 
termination. 
 
There are a four allowable exceptions to the sale or transfer prohibition at 424.550(b)(2).  
Specifically, the provisions of 424.550(b)(1) do not apply if: 
 
  The HHA submitted two consecutive years of full cost reports (which are not low 
utilization or no utilization cost reports); 
  The HHA parent company is undergoing an internal corporate restructuring, such 
as a merger or consolidation; 
  The owners of an existing HHA are changing the HHAs existing business 
structure and the owners remain the same; or    An individual owner of an HHA dies. 
 
Note:  424.550(b)(1) does not apply to indirect changes in majority ownership (e.g., 
changes to the ownership of a holding company that owns and operates HHAs through 
subsidiaries). 
 
Voluntary Terminations 
 
In accordance with 489.52 and 2005 and 3046, a Medicare approved HHA may 
voluntarily terminate its provider agreement by filing a written notice of its intention to 
the State Agency who, in turn, notifies the RO.  The provider/supplier must also submit a 
Form CMS-855A or CMS-855B to voluntarily terminate its Medicare billing privileges.  .  
 
NOTE: According to Pub. 100-08, chapter 10, section 7.3:  In the event the HHA notifies 
the MAC of its intent to voluntarily terminate, the MAC shall notify the State and RO.  
This notification can be made via letter, e-mail, or fax, no later than 3 business days after 
the contractor has finished processing the termination.  
 
CMS recommends that an HHA provide a discharge comprehensive assessment for each 
patient prior to the effective date of the termination of its provider agreement.  
 
The former HHA that meets the 2010 revised HHA CHOW definition is considered to 
have voluntarily terminated the original provider agreement. The State should follow 
usual procedures regarding voluntary termination, using the date of the CHOW as the 
effective date of voluntary termination. Electronic communication with the MAC should 
occur between all interested parties. 
 
Involuntary Terminations 
 
The RO may terminate the provider agreement with an HHA, in accordance with 489.53.  
Revocation of billing privileges in the Medicare program may be initiated by the MAC at 
424.535, which results in termination of the provider agreement.  When revocation of 
billing privileges also results in the termination of a corresponding provider agreement, 
the provider may appeal CMSs decision under 498, where a final decision applies to 
both the billing privileges and the provider agreement. See 424.545. 
 
CMS will work with the HHA on a case-by-case basis to provide for the safe and orderly 
transfer of patients to another Medicare-approved HHA if appropriate.  
 
Deactivation of billing privileges 
 
Under 424.540, a provider or supplier who does not submit any Medicare claims for 12 
consecutive calendar months will have its Medicare billing privileges deactivated.  The 12 
month period begins on the 1st day of the 1st month without claims submission through 
the last day of the 12th month without a submitted claim.  Deactivated agencies are not 
terminated and are still required to be surveyed every 36 months by the SA or AO, if 
deemed.   
Effective January 1, 2010, if an HHAs billing privileges are deactivated, the HHA must 
also undergo a Medicare survey in order for its billing privileges to be reactivated.  This 
applies to all applications for reactivation that were received after December 31, 2009.  
 
In order for its billing privileges to be reactivated, a HHA must first submit a Form CMS-
855 update (re-activation application) to the MAC.  The MAC will conduct its preliminary 
review of the application and either deny the application or notify the RO, AO or SA that 
a survey may be scheduled.  The MAC will notify the provider that the preliminary review 
is complete and that the SA has been notified. 
 
Once the RO/SA receives notification from the MAC, surveys of deactivated HHAs are 
scheduled as a low survey priority.  In circumstances of demonstrated access to care 
issues, the RO may change the survey priority and determine if an earlier recertification 
survey is indicated. 
If an HHA chooses to have a deemed status survey by an AO, it is the responsibility of the 
HHA to arrange the Medicare recertification or initial survey with the AO.  The AO shall 
perform a recertification survey for existing clients when billing privileges have been 
deactivated and the agency has subsequently requested reactivation. In the event the HHA 
wishes to use the AO to conduct a reactivation survey when it formerly was under the 
jurisdiction of the SA, the AO would conduct this as an initial survey.  The AO must 
notify the RO of the survey findings and the deeming recommendation.  The RO retains 
the responsibility to notify the MAC that the agency passed the requirements of the 
Medicare survey. 
 
A standard survey is conducted and entered into the ASPEN system as a recertification 
survey along with a note that this is an early recertification due to a request for 
reactivation of Medicare billing.  The SA must notify the RO of the survey activity.  If the 
survey finds condition level non-compliance, routine enforcement procedures should be 
followed.  If the survey finds substantial compliance, the RO should forward Form CMS-
2007 to the MAC with the date the provider was determined to be in compliance with the 
CoPs in the remarks section.  The HHA will retain its existing CMS CCN. 
 
2202.18 - Wound Ostomy Continence Nurses Society (WOCN) and the 
National Pressure Ulcer Advisory Panel (NPUAP) OASIS Guidance 
(Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 
 
The CMS collaborates with clinical wound care experts from the WOCN and the NPUAP 
to clarify OASIS wound items. The clarifications are intended to be helpful to home health 
agency (HHA) clinicians as they complete their patient assessments.  For more 
information about the WOCN guidelines and for answers to questions about the WOCN 
guidelines, please contact the WOCN web site at http://www.wocn.org. 
 
HHA clinicians are encouraged to use the WOCN and the NPUAP guidance to assist with 
clinical assessments of patient wounds.  The WOCN OASIS Guidance is located at: 
http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf (http://www.wocn.org ) and the 
NPUAP website is located at http://www.npuap.org/.   
2202.19 - OASIS Collection on Private Pay (Non-Medicare/Non-
Medicaid) Patients 
(Rev. 1, 05-21-04) 
 
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 includes a 
provision regarding the collection of OASIS data for non-Medicare/non-Medicaid (private pay) 
patients.  Specifically, section 704 of this Act temporarily suspends the requirement that 
Medicare-approved HHAs collect OASIS data on non-Medicare/non-Medicaid patients, 
effective December 8, 2003.  Ambulatory Surgical Centers (ASCs) 
 
2210 - ASCs - Citations and Description 
(Rev. 1, 05-21-04) 
 
Section 1832(a)(2)(F) of the Social Security Act (the Act) provides that, as an adjunct to 
outpatient surgical services, ASC facility services can be paid under Part B of the 
Medicare program.  Though it is a supplier, an ASC must be certified and approved to 
enter into a written agreement with CMS.  The Conditions for Coverage of ASC services 
are found in 42 CFR 416.  Interpretive guidelines and surveyor procedures are in 
Appendix L. 
 
Participation as an ASC is limited to any distinct entity that operates exclusively for 
purposes of providing surgical services to patients not requiring hospitalization (i.e., an 
inpatient stay in a hospital).  The regulatory definition of an ASC (42 CFR 416.2) does not 
allow the ASC and another entity to mix functions and operations in a common space 
during concurrent or overlapping hours of operations.  Our current regulations and policy 
do not allow an entity to function both as an ASC and an Independent Diagnostic Testing 
Facility (IDTF), mixing unrelated functions and operations in a common space during 
concurrent or overlapping hours of operation.  That is, the two facilities must be separated 
by time (different hours of operation) or the other entity may operate in the ASCs space 
when the space is not operating in that space.  
 
An exception to this rule is when there is a need for imaging services during the course of 
a procedure in progress at an ASC, the IDTF sharing the space with the ASC (but a 
different time), may conduct the required service outside of its normal business hours, as 
needed, and receive Medicare payment for those services.  In this situation, our 
regulations and regulations and policy allow the IDTF to bill and receive Medicare 
payment for imaging and guidance services (such as angiography, venography, 
fluoroscopy, and ultrasonic needle guidance) that are reasonable and necessary and 
directly related to the performance of a surgical procedure and furnished in 
conjunction with a surgical procedure despite being conducted during the ASCs 
designated hours.  
 
The operating room(s) and recovery room(s) are to be used only for patients having 
surgery.  The ASC must also have a separate recovery room and waiting area.  
(See 42 CFR 416.44(a)(2)). 
 
An ASC may be either hospital-operated or independent.  The hospital-operated ASC 
must be a separately identified entity.  It must be physically and administratively distinct 
from other operations of the hospital and be able to identify its costs separately from other 
hospital costs.  A hospital ASCs agreement is made effective prospectively at the start of 
the hospitals next cost reporting year.  (See 42 CFR 416.30(f)(1).) 
 
The ASC may not perform a surgical procedure on a Medicare beneficiary when, before 
surgery, an overnight hospital stay is anticipated.  There may, however, arise 
unanticipated medical circumstances that warrant a beneficiarys hospitalization after an  ASC surgical procedure.  The ASC must have procedures for the immediate transfer of 
these patients to a hospital (42 CFR 416.41).  Such situations should be infrequent. 
 
ASC covered procedures (see 42 CFR 416.65) are those that generally do not exceed 90 
minutes in length and do not require more than four hours recovery or convalescent time. 
Therefore, ASC patients generally do not require extended care as a result of ASC 
procedures.  An unanticipated medical circumstance may arise that would require an ASC 
patient to stay in an overnight health care setting.  Such situations should also be 
infrequent. When extended care in a non-hospital health care setting is anticipated as a 
result of a particular procedure, that procedure would not be a covered ASC procedure for 
beneficiaries. 
 
The SA follows standard procedures for identifying interested ASCs and certifying them.  
If the ASC operates other activities as part of the same enterprise, the SA forwards a 
request for certification, Form CMS-377, (Exhibit 64) with a Certification and 
Transmittal, Form CMS-1539, to the RO, together with any evidence covering the 
activities operated.  Copies of the ASC Health Insurance Benefits Agreement, Form CMS-
370 (Exhibit 65) are signed and processed in the same manner as provider agreements. 
    Rural Health Clinics (RHCs) 
 
2240 - RHCs - Citations and Description 
 
(Rev. 1, 05-21-04) 
 
The statutory basis for RHCs is found in 1861(aa) of the Act.  The Conditions for 
Certification are in 42 CFR 491, Subpart A.  Appendix G contains interpretive guidelines 
and surveyor procedures. An RHC is a facility located in a rural area designated as a 
shortage area and is neither a rehabilitation agency nor a facility primarily for the care and 
treatment of mental diseases.  It meets all other requirements of the RHC regulations at 
42 CFR 491, Subpart A.  A clinic located on an island may be eligible to be certified as an 
RHC even though it does not have a physician assistant, nurse practitioner, or certified 
nurse-midwife.  (See 6213 of OBRA 1989.) 
 
2242 - Conditions to Be Assessed Prior to Scheduling RHC Survey 
 
(Rev. 1, 05-21-04) 
 
2242A - General 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
Applicants seeking initial certification as an RHC must, among other requirements, satisfy 
certain location and staffing requirements in order to participate in Medicare.   In order to 
facilitate an efficient survey and certification process for applicants, State Survey 
Agencies and CMS, CMS requires an RHC applicant to complete and submit Form CMS-
29, Verification of Clinic Data  Rural Health Clinic Program, as part of its application for 
certification.  To make efficient use of survey resources, State Survey Agencies (SAs) 
make a preliminary assessment of the information contained on the Form CMS-29 prior to 
conducting a survey, to avoid conducting a survey of an ineligible location.  Likewise SAs 
conduct a preliminary assessment of the information contained on the Form CMS-29 prior 
to forwarding a certification packet to the RO when the RHC applicant is seeking to 
participate via deemed status accreditation.  However, since only the CMS RO may make 
a determination whether the RHC applicant has satisfied all Federal requirements, 
including the location and staffing requirements, the SA must not notify the applicant of 
the results of the SAs preliminary assessment of the Form CMS-29. 
 
The SA or an accrediting organization (AO) may not conduct a survey before receiving a 
positive recommendation from the Medicare Administrative Contractor (MAC), issued 
after the MAC has completed its review of the RHC applicants Form CMS-855A 
application to enroll in Medicare.  An AO must receive a copy of the MACs notice to the 
applicant that it has concluded its review before conducting an accreditation survey.   
 
CMS makes RHC location determinations only after an RHC applicant has submitted an 
application to enroll in Medicare and is open and operating at the site identified in the 
application.  CMS does not provide advance or preliminary determinations about whether 
a location satisfies the RHC criteria, even if interested parties request one.  SAs also may  not issue any preliminary or final assessments about a locations potential eligibility for 
RHC status. 
 
2242A1 - Location of Clinic 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
Subpart A of 42 CFR Part 491 sets forth the conditions that RHCs must meet in order to 
qualify for certification under Medicare.  Question I on Form CMS-29 identifies the 
location of the clinic and defines location as the location at which health services are 
furnished.   
In accordance with 42 CFR 491.5, the clinic must be located in a rural area that is 
designated as a shortage area. 
 
  A rural area is defined in 42 CFR 491.2 as an area that is not delineated as an 
urbanized area by the US Census Bureau.  An urban cluster is not considered 
an urbanized area.  CMS relies upon the information in the US Census Bureaus 
American FactFinder tool, 
http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml, when determining 
whether a location falls within a rural area.  Note that once a RHC is certified for 
Medicare participation, it may continue to participate as an RHC even if the US 
Census Bureau subsequently changes the classification of its location to an 
urbanized area. 
 
  A shortage area is a defined geographic area designated by the Health Resources 
and Services Administration (HRSA) on behalf of the Secretary as having either a 
shortage of personal health services or an area or population group with a shortage 
of primary medical care manpower.  HRSA may also designate at the request of a 
State governor specified areas of a State as having a shortage of personal health 
services.  CMS uses data from HRSAs Data Warehouse, 
http://www.hrsa.gov/shortage/find.html, supplemented as needed by information 
obtained via telephone or e-mail from HRSA, when determining whether a 
location falls within a shortage area.  
 
SAs may use these same on-line tools when conducting their preliminary assessments of 
an RHC applicants location prior to conducting a survey, but the results of their 
assessments are not considered determinations by CMS.  AOs may also use these tools 
when deciding whether to accept an application for RHC accreditation and conduct an 
accreditation survey.  However, SAs and AOs are not authorized to provide notice to the 
RHC applicant of the results of their assessments.  Further, the fact that the SA, or an AO 
with a CMS-approved Medicare RHC accreditation program, conducts a survey of the 
RHC applicant does not constitute a determination by CMS that the applicants location 
satisfies the regulatory criteria.  Only the CMS RO may make such a determination and 
notify the applicant whether or not it has been determined to meet participation 
requirements. 
 
Relocating an Existing RHC 
An existing Medicare-certified RHC that has relocated must submit a CMS-855A  updating the location information to the appropriate MAC within 90 days after it relocates.  
(See section 15.10.1 of the Medicare Program Integrity Manual, CMS Pub. 100-08).  CMS 
also does not provide advance determinations on the location eligibility of a potential 
relocation site.  Rural and shortage area location determinations are only made after the 
relocation has occurred and the CMS-855A has been submitted to the appropriate MAC.  
The RHC must also submit to the SA a Form CMS-29 reflecting its new location at the 
same time that it submits the CMS-855A update to the MAC.  The SA forwards this 
information to the RO, which reviews it to determine whether the RHC at the new location 
continues to meet the location requirements.  If it does not, the RO will issue a termination 
notice to the RHC.  If the new location does continue to meet the RHC requirements, the 
RO does not need to take any further action, beyond documenting its determination in the 
RHCs certification file.  However, based on the information on the Form CMS-29, the 
RO also has the discretion to require an on-site survey of the RHC at the new location. 
 
If the RHC is only changing suites within the same building, CMS would not consider this 
a relocation.  However, the RHC must still report the change of information to the MAC 
using the CMS-855A. 
 
2242A2 - Medical Direction 
 
(Rev. 1, 05-21-04) 
 
Question II on Form CMS-29 asks for the name and address of the physician(s) providing 
the clinics medical direction.  The physician(s) providing medical direction must be a 
member of the clinics staff or under agreement with the clinic to carry out the 
responsibilities required of a physician. If performed in the clinic, the time spent in this 
medical direction must be included in the answer to question III.A. 
 
2242A3 - Physician Assistant, Nurse Practitioner, and/or Certified Nurse 
Midwife Staff 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
Question III.B. and/or III.C. on Form CMS-29 indicates whether the clinics staff includes 
a physician assistant, nurse practitioner, and/or certified nurse-midwife.  A nurse 
practitioner, a physician assistant, or certified nurse-midwife must be available to furnish 
patient care services at least 50 percent of the time the clinic operates.  (See Appendix G.)  
The SA contacts the clinic for clarification if the combined full-time equivalent entries in 
question III.B. and C. (and/or D., if D. is used to indicate a nurse-midwife) do not equal 50 
percent of the clinics scheduled hours of operation.  In computing the full-time 
equivalents, the SA uses only the time personnel are present in the clinic or are providing 
RHC services away from the clinic site.   The results of the SAs preliminary assessment 
of the staffing information on the Form CMS- 29 do not constitute a determination by 
CMS, and the SA may not provide notice to the applicant of the results of its assessment.  
Likewise, any information or advice provided by an AO to the applicant about meeting the 
basic staffing eligibility requirements does not constitute a determination by CMS. 
 
The SA (or AO) may proceed to conduct a survey of the RHC applicant based on the  results of its preliminary assessment of the applicants staffing information, but the fact 
that the SA or AO conducted a survey does not constitute a determination by CMS that the 
RHC applicant meets the basic staffing requirements. 
 
An RHC which is already certified and participating in Medicare may request a temporary 
waiver of these staffing requirements for a one-year period, if it demonstrates that it has 
been unable to hire a physician assistant, nurse-practitioner, or a certified nurse-midwife 
in the previous 90-day period.  However, staffing waivers are not available to RHC 
applicants seeking initial enrollment in the Medicare program. 
 
A subsequent request for a waiver cannot be made less than 6 months after the expiration 
date of any previous waiver of staffing requirements for the facility. 
 
2242B - Clinic Is Determined Ineligible 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
If the SAs preliminary assessment of the Form CMS-29 suggests that the RHC 
applicants location does not satisfy the RHC eligibility requirements, the SA must notify 
the RO of this, forwarding the Form CMS-29.  The RO will independently assess the 
location requirements, and if it concurs with the SA, the RO will issue a denial of initial 
certification to the applicant based on its determination regarding the applicants location. 
 
Likewise, if the SAs preliminary assessment of the Form CMS-29 suggests that the 
applicant does not have the minimum required physician assistant, nurse practitioner 
and/or certified nurse/midwife staff, the SA must notify the RO of this, forwarding the 
Form CMS-29.  The RO will independently assess the staffing information contained on 
the Form CMS- 29, and if it concurs with the SA, the RO will issue a denial of initial 
certification to the applicant based on its determination regarding the applicants self-
reported staffing information. 
 
2242D - Identifying Clinic as Provider-Based 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
If the RHC applicant submits a Form CMS-29 indicating that it is a provider-based entity 
of a critical access hospital (CAH) or eligible hospital, the SA confirms the accuracy of 
the CAHs or hospitals CMS Certification Number (CCN) entered on the form.  After 
conducting a survey and/or receiving notice of an AOs recommendation of RHC deemed 
status for the applicant, the SA forwards the Form CMS-29 and other certification 
documentation to the RO for review and a certification determination.  If the RHC meets 
all Federal requirements for certification, and has indicated on its Form CMS-29 that it is 
provider-based to a hospital or CAH, the RO will issue a Medicare RHC agreement with a 
provider-based RHC CCN. 
 
Issuance of a Medicare provider agreement with a provider-based CCN to a RHC 
does not constitute a CMS provider-based determination as provided for in 
413.65(b).  Seeking such a provider-based determination is voluntary, and neither the SA 
nor the RO may require RHC applicants and their affiliated hospitals/CAHs to seek such a  determination as a condition to being issued a provider-based RHC CCN. 
 
However, when CMS issues a provider-based RHC CCN, the letter approving the RHCs 
provider agreement and issuing the CCN must contain the following disclaimer language: 
Issuance of a provider-based RHC CCN does not constitute a CMS provider-based 
determination. 
 
2242E - Compliance With Civil Rights Statutes 
 
(Rev. 1, 05-21-04) 
 
An RHC that only received Federal funds through Medicare Part B is not required to 
comply with the various civil rights statutes enforced by the Department of Health and 
Human Services (DHHS) Office for Civil Rights.  However, if the RHC participates in 
the Medicaid program or receives any other financial assistance such as grants from 
DHHS, it must comply with all applicable civil rights statutes.  RHCs are not subject to 
the pre-grant review process required of participants in Medicare Part A. 
 
2242F - Laboratory Services Provided in RHCs 
 
(Rev. 1, 05-21-04) 
 
An RHC must provide primary health care, including laboratory services to its patients.  
The RHCs laboratory services are subject to the Clinical Laboratory Improvement 
Amendments (CLIA).  
 
2244 - Preparing for RHC Survey 
 
(Rev. 1, 05-21-04) 
 
Prior to the survey, in addition to reviewing the information and references needed for 
surveys generally, the SA reviews: 
 
  Listings of formal educational programs for physician assistants, nurse 
practitioners, and certified nurse midwives; and 
 
  A list of formal educational programs supported under HRSA grants to prepare 
RNs to perform in an expanded role in the delivery of primary care and any other 
educational programs that meet the requirements of the regulation. 
 
2246 - Clinics Request to Provide Visiting Nurse Services 
 
(Rev. 1, 05-21-04) 
 
An approved RHC may also seek approval to provide covered visiting nurse services.  An 
RN, LPN, or licensed vocational nurse must furnish these services. 
  When a request is received, the SA determines if a shortage of HHAs exists in the area.  
Refer to 42 CFR Part 405.2417 and consults with the RO, as appropriate.  If there is an 
existing HHA furnishing services in the RHC area, the SA contacts the HHA for a 
statement of its ability or inability to adequately furnish nursing services in the area.  In 
addition, the SA obtains information from the local or State health planning organization. 
 
If there is not a shortage of home health services for the area, the SA notifies the RO.  In 
such cases, approval to furnish visiting nursing services to homebound patients will not be 
granted, and the RHC must refer its homebound patients to the HHA serving the area. 
 
If there is a shortage of home health services, the SA notifies the RO and evaluates the 
qualifications of RHC personnel who are responsible for the delivery of nursing services.  
This evaluation must include compliance with applicable State licensure/certification 
requirements for RNs, LPNs, or licensed vocational nurses who provide services for the 
clinic. 
 
2248 - Clinics Request for Waiver of Staffing Requirements 
 
(Rev. 1, 05-21-04) 
 
As provided by 1861(aa)(7) of the Act, the Secretary of HHS is required to grant a 1-year 
waiver to RHCs for staffing requirements that the clinic employ a nurse practitioner, 
physician assistant, or certified nurse midwife, or that such disciplines furnish services 50 
percent of the time that the clinic operates if: 
 
  The facility requests a waiver; 
 
  The facility demonstrates that it has been unable, despite reasonable efforts, to hire 
a physician assistant, nurse practitioner, or certified nurse midwife in the previous 
90-day period; and 
 
  The facility is not making the request less than 6 months after the date of the 
expiration of any previous such waiver for the facility. 
 
The waiver is applicable to participating RHCs.  The SA is responsible for recommending 
approval or disapproval of the requested waiver to the RO within 30 days of receiving it.  
The waiver shall be deemed granted unless the waiver request is denied by the RO within 
60 days after the date the SA received the request.  In such situations the effective date of 
the 1-year waiver is the 61st day after the date the request is received by the SA.  The SA 
uses the date the RO approves the waiver as the effective date of the 1-year waiver period. 
 
2248A - Applying Waiver to Applicants 
 
(Rev. 1, 05-21-04) 
 
The initial packet of information sent to RHC applicants by the SA should include a 
statement that the applicant cannot request a waiver of the mid-level requirement on initial  application.  In 4205(c) of the BBA, the Congress amended, effective January 1, 1998, 
1861(aa)(7)(B) of the Act to restrict further our authority to waive the requirement that 
each RHC must hire a physician assistant, nurse practitioner, or certified nurse midwife.  
A waiver may now be granted only to a participating RHC.  That is, the waiver cannot be 
granted before the clinic has been determined by us to meet all the requirements for 
Medicare participation as an RHC and is actually participating as an RHC. 
 
2248B - Applying Waiver to Participating RHCs 
 
(Rev. 1, 05-21-04) 
 
A participating RHC may request a waiver either when it loses its nurse practitioner, 
physician assistant, or certified nurse-midwife, or when it fails to meet the 50 percent 
staffing requirement regarding these disciplines. 
 
Some RHCs will probably experience an unexpected loss of staff and therefore will not be 
able to demonstrate any effort to hire staff in the previous 90-day period.  The SA should 
advise an RHC that it must comply with the staffing requirement within 90 days from the 
date it informed the SA it no longer met the staffing requirements or be terminated unless 
a waiver request is submitted by the facility and approved by the RO at the end of the 90-
day period. 
 
2248C - Documentation Demonstrating Efforts to Meet Staffing 
Requirements 
 
(Rev. 1, 05-21-04) 
 
An RHC must submit written documentation to the SA demonstrating its reasonable 
efforts to hire the required staff.  This documentation should evidence ongoing activities 
throughout the 90-day time period prior to making a waiver request.  The following types 
of documentation would be acceptable: 
 
  Copies of reports of telephone contacts with potential hires, professional schools 
and organizations, recruiting services, etc.; 
 
  Information about trips to professional meetings, educational institutions, and 
health care facilities for recruiting purposes; 
 
  Copies of advertisements for recruiting hires; and 
 
  Results of personal interviews with potential hires. 
 
2248D - Monitoring Waivers 
 
(Rev. 1, 05-21-04) 
 
The SA monitors the expiration dates of waivers.  When the expiration date of an RHCs  waiver is imminent, the SA must contact the RHC to determine whether the RHC will be 
in compliance with 42 CFR Part 491.8 as of the expiration date of the waiver. 
 
If it is determined that the RHC will not be in compliance with 42 CFR Part 491.8 as of 
the expiration date of the waiver, the SA notifies the RHC that it will be terminated from 
the Medicare program.  The RHC should be given notice of the termination at least 15 
days before the effective date of the termination date.  The termination date cannot be 
earlier than the day after the expiration date of the waiver. 
 
If the RHC provides evidence that it has hired the required staff, but the staff will not be 
available at the clinic until after the expiration date of the waiver, the SA initiates 
termination action pursuant to 3012.  The SA informs the RHC that when it meets the 
staffing requirement it should notify you immediately. 
 
2248E - Notification 
 
(Rev. 1, 05-21-04) 
 
Both the SA and the ROs should notify an RHC when an RHCs waiver has been 
approved and include an explanation of the above termination procedures for expired 
waivers. 
 
2249 - RO Notification of RHC Initial Certification Approval 
(Rev. 139, Issued: 04-24-15, Effective: 04-24-15, Implementation: 04-24-15) 
 
The SA forwards to the RO its survey report or the AOs notice of accreditation and 
recommendation of deemed status, along with any other supporting documents required in 
the RHC certification packet.  The RO reviews all documentation to determine whether 
the applicant is or is not in compliance with all RHC requirements. The RO notifies an 
applicant of its approval or denial of certification in writing.  If the applicant is approved, 
the RO countersigns, dates and issues the Form 1561A, Health Insurance Benefits 
Agreement, Rural Health Clinic, along with a cover letter indicating the RHCs CCN and 
the effective date of the Agreement.  See 2784 which governs how the RO determines 
the effective date of participation. 
 
  The RO sends a copy of Form CMS-2007 to the Medicare Administrative 
Contractor (MAC) and another to the State Medicaid Agency (SMA) that has 
billing jurisdiction for RHCs. 
 
  The RO sends a copy of the letter issuing the clinics agreement to the Regional 
Health Administrator, HRSA, so that appropriate notification may be given to 
components of the PHS engaged in program support for rural health service 
activity. 
 
The RO adds the following paragraph to the letter accepting the RHCs agreement: 
 
Your participation as an RHC under the Medicare program will also be  accepted as certification as an RHC under the Medicaid program.  If you 
need information about payment for RHC services under the State plan for 
medical assistance, contact (name, address, and telephone number of 
appropriate SMA). 
 
If a provider-based CCN is being issued, the approval letter must contain the following 
explicit language: "Issuance of a provider-based RHC CCN does not constitute a CMS 
provider-based determination.  Community Mental Health Centers 
 
2250 - Community Mental Health Centers (CMHC) - Citations and 
Descriptions 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
NOTE: Recognition of marriages: Every psychiatric hospital/facility is expected to 
recognize all lawful marriages and spouses for purposes of compliance with the 
Conditions of Participation and regulatory requirements. In this guidance, and in every 
instance where the following terms appear: 
 
  Spouse means an individual who is married to another individual as a result of a 
marriage that was lawful where entered into, including an individual married to an 
individual of the same-sex. 
 
  Marriage means a marriage that was lawful where entered into, including 
a marriage of two individuals of the same sex; 
 
  Family includes, but is not limited to, an individuals spouse (see above); and, 
 
  Relative, when used as a noun, includes, but is not limited to 
an individuals spouse (see above). 
 
Furthermore, wherever the text of a regulation or associated guidance includes a 
reference to a patients representative, surrogate, support person, next-of-kin, or 
similar term in such a manner as would normally implicitly or explicitly include a 
spousal relationship, the terms are to be interpreted as indicated above. 
 
2250A - Citations and Definitions 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
Citations 
Section 4162 of P.L. 101-508 (OBRA 1990), amended 1861(ff)(3)(A) and 
1832(a)(2)(J) of the Act to include CMHCs as entities that are authorized to provide 
partial hospitalization services under Part B of the Medicare program, effective October 
1, 1991. Applicable regulations are found at 42 CFR Chapter IV, Parts 400, 410, 424, 
485 and 489.  The Conditions of Participation (CoPs) were published on October 29, 
2013 and were effective on October 29, 2014. 
 
Definitions 
 
Community Mental Health Center (CMHC) is as defined in 410.2: an entity that- (1) 
Provides outpatient services, including specialized outpatient services for children, the 
elderly, individuals who are chronically mentally ill, and clients of its mental health 
service area who have been discharged from inpatient treatment at a mental health  facility; (2). Provides 24-hour-a-day emergency care services; (3) Provides day 
treatment or other partial hospitalization services, or psychosocial rehabilitation 
services; (4) Provides screening for patients being considered for admission to State 
mental health facilities to determine the appropriateness of this admission; (5) Meets 
applicable licensing or certification requirements for CMHCs in the State in which it is 
located; and (6) Provides at least 40 percent of its services to individuals who are not 
eligible for benefits under title XVIII of the Social Security Act. 
 
Active treatment plan means an individualized client plan that focuses on the provision 
of care and treatment services that address the clients physical, psychological, 
psychosocial, emotional, and therapeutic needs and goals as identified in the 
comprehensive assessment. 
 
Comprehensive assessment means a thorough evaluation of the clients physical, 
physiological, psychosocial, emotional, and therapeutic needs related to the 
diagnosis under which care is being furnished by the CMHC. 
Initial evaluation means an immediate care and support assessment of the clients 
physical, psychosocial (including a screen for harm to self or others), and 
therapeutic needs related to the psychiatric illness and related conditions for which 
care is being furnished by the CMHC. 
 
Representative means an individual who has the authority under State law to authorize 
or terminate medical care on behalf of a client who is mentally or physically 
incapacitated. This includes a legal guardian. 
 
Restraint means (1) Any manual method, physical or mechanical device, material, or 
equipment that immobilizes or reduces the ability of a client to move his or her arms, 
legs, body, or head freely, not including devices, such as orthopedically prescribed 
devices, surgical dressings or bandages, protective helmets, or other methods 
that involve the physical holding of a client for the purpose of conducting routine 
physical examinations or tests, or to protect the client from falling out of bed, or to 
permit the client to participate in activities without the risk of physical harm (this does 
not include a client being physically escorted); or (2) A drug or medication when it is 
used as a restriction to manage the clients behavior or restrict the clients freedom of 
movement, and which is not a standard treatment or dosage for the clients condition. 
 
Partial Hospitalization Services (PHS) is as defined in 410.2:Partial hospitalization 
services means a distinct and organized intensive ambulatory treatment program that 
offers less than 24-hour daily care other than in an individuals home or in an inpatient 
or residential setting and furnishes the services as described in  410.43. Per 410.43 
(a) Partial hospitalization services are services that(1) Are reasonable and necessary 
for the diagnosis or active treatment of the individuals condition; (2) Are reasonably 
expected to improve or maintain the individuals condition and functional level and to 
prevent relapse or hospitalization;(3) Are furnished in accordance with a physician 
certification and plan of care as specified under  424.24(e) of this chapter; and (4) 
Include any of the following: (i) Individual and group therapy with physicians or 
psychologists or other mental health professionals to the extent authorized under State  law. (ii) Occupational therapy requiring the skills of a qualified occupational therapist, 
provided by an occupational therapist, or under appropriate supervision of a qualified 
occupational therapist by an occupational therapy assistant as specified in part 484 of 
this chapter. (iii) Services of social workers, trained psychiatric nurses, and other staff 
trained to work with psychiatric patients. (iv) Drugs and biologicals furnished for 
therapeutic purposes, subject to the limitations specified in  410.29. (v) Individualized 
activity therapies that are not primarily recreational or diversionary. (vi) Family 
counseling, the primary purpose of which is treatment of the individuals condition. (vii) 
Patient training and education, to the extent the training and educational activities are 
closely and clearly related to the individuals care and treatment. (viii) Diagnostic 
services. (b) The following services are separately covered and not paid as partial 
hospitalization services: (1) Physician services that meet the requirements of 
415.102(a) of this chapter for payment on a fee schedule basis. (2) Physician assistant 
services, as defined in section 1861(s)(2)(K)(i) of the Act. (3) Nurse practitioner and 
clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (4) 
Qualified psychologist services, as defined in section 1861(ii) of the Act. (5) Services 
furnished to SNF residents as defined in  411.15(p) of this chapter. (c) Partial 
hospitalization programs are intended for patients who(1) Require a minimum of 20 
hours per week of therapeutic services as evidenced in their plan of care; (2) Are likely 
to benefit from a coordinated program of services and require more than isolated 
sessions of outpatient treatment; (3) Do not require 24-hour care; (4) Have an adequate 
support system while not actively engaged in the program; (5) Have a mental health 
diagnosis; (6) Are not judged to be dangerous to self or others; and (7) Have the 
cognitive and emotional ability to participate in the active treatment process and can 
tolerate the intensity of the partial hospitalization program. 
 
Day Treatment Services generally include person-centered, culturally and linguistically 
appropriate, comprehensive, coordinated, structured treatment services and activities. A 
day treatment program consists of a scheduled series of structured, face-to-face 
therapeutic sessions organized at various levels of intensity and frequency in order to 
assist the persons served in achieving the goals identified in their person-centered plans. 
Day treatment programs are offered four or more days per week, typically with support 
available in the evenings and on weekends. A day treatment program may prevent or 
minimize the need for a more intensive level of treatment. It may also function as a step- 
down from inpatient care or partial hospitalization or, as transitional care following an 
inpatient or partial hospitalization stay to facilitate return to the community. 
 
Psychosocial Rehabilitation Services (PSR) are activities aimed at reintegrating the 
individual back into society by improving their functioning and ability to comply with 
rules and expectations of the community and are consistent with the identified goals or 
objectives of the clients active treatment plan. This includes the fullest possible 
integration of the client as an active and productive member of his or her family, 
community, and/or culture with the least amount of structured professional intervention. 
Services may be provided individually or in a group setting. 
 
Seclusion means the involuntary confinement of a client alone in a room or an area 
from which the client is physically prevented from leaving.   
Children are defined by Medicare as an unmarried person younger than 22 years 
old.  Surveyors should also be aware of their State law for defining a child, based 
on where the CMHC is located. 
 
Elderly refers to an individual who is aged 65 years and older. 
 
2250B - Special Requirements 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
A CMHC is required to submit a certification statement, provided by an independent 
licensed professional, to certify that the CMHC client population meets the 40 percent 
requirement as specified in 42 CFR 485.918(b)(1)(v)(A) and 42 CFR  
485.918(b)(1)(v)(B). The certification statement is required upon initial application to 
enroll in the Medicare program and as part of provider enrollment revalidation. The 
statements are submitted to the applicable Medicare Administrative Contractor. 
Medicare enrollment may be denied or revoked in instances where the CMHC fails to 
provide the certification statement as required.  The CMHC and individuals furnishing 
services on its behalf must meet applicable State licensure requirements. 
 
2250C - Partial Hospitalization Services Provided by CMHCs or by 
Others Under Arrangements With the CMHC 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
Per section 1866(e)(2) of the Act CMHCs are recognized as Medicare providers only 
with respect to providing partial hospitalization services and under regulations at 42 CFR 
489.2(c)(2) CMHCs may only enter into provider agreements under Medicare to 
furnish partial hospitalization services. If during the course of a survey it is determined 
that the CMHC does not provide partial hospitalization services, the surveyor should 
document this finding in the CMS-2567 Statement of Deficiencies and Plan of 
Correction under Tag 000 Initial Comments. The survey should be completed, 
despite this finding. The surveyor should include in their documentation all information 
collected to confirm that the provider is not providing PHS, including documentation 
from records reviewed and interviews.  
 
Even if the CMHC is found to be in compliance with the CoP in 485.918 Organization, 
Governance, Administration of Services, and Partial Hospitalization Services, the CMHC 
may not enter into, or continue, a provider agreement with CMS unless the CMHC 
chooses to provide partial hospitalization services. If the CMHC does not choose to 
either provide partial hospitalization services, or to voluntarily terminate its Medicare 
provider agreement, CMS may exercise its authority to terminate the provider agreement 
pursuant to 489.53. 
 
In order for a CMHC to demonstrate that they are providing Partial Hospitalization 
Services, the following program service requirements must be met pursuant to 
410.43: 
  1)  Physician approved (ideally a psychiatrist) certification or active treatment 
plans for clients; 
 
2)  Both individual and group therapy services facilitated by approved mental 
health professionals to the extent authorized under State law; 
 
3)  Occupational therapy services to the extent authorized under State law; 
 
4)  Services provided by social workers, psychiatric nurses and other staff trained 
to work with psychiatric clients; 
 
5)  Drugs and biologicals furnished for therapeutic purposes; 
 
6)  Individual therapy services not primarily for recreational or diversionary reasons 
(examples: Games, outings, gardening, computers, gentle exercise, music, arts and 
crafts); 
 
7)  Family counseling, primarily focused on or addressing the clients 
psychiatric condition; 
 
8)  Training and education services that are directly related to the clients 
individual active treatment plan; and 
 
9)  Diagnostic services (example: psychological testing).  
 
2251 - Certification Process 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
2251A  Request to Participate 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
The CMHC notifies the State Survey Agency (SA) that it wishes to participate. The SA 
ensures that the CMHC submits a CMS-855A to the Medicare Administrative 
Contractor (MAC) and forwards information to the applicant concerning the procedure 
for Office of Civil Rights clearance. Once the MAC has completed its review, 
including a review of the facility certification statement that at least 40% of the 
CMHCs items and services are provided to non- eligible individuals, it will forward an 
approval recommendation notice to the appropriate CMS Regional Office (RO) and the 
SA. The SA will schedule an initial survey for the CMHC according to the CMS 
Mission and Priority Document (MPD). 
 
2251B  Initial Survey/Certification-SA Role 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
The SA evaluates whether the applicant meets the CoPs and applicable licensing 
requirements in the State through an on-site survey. Include within the survey process,  the requirements as stated in section 2250C of the SOM. A CMHC may be certified 
with Standard level deficiencies as long as an acceptable plan of correction is submitted. 
However, a CMHC may not be certified with a Condition level deficiency or if it does 
not provide PHS. The SA will forward its recommendation for certification or denial of 
certification to the RO. The SA will process the certification packet pursuant to 
applicable instructions in 2760-2776.  
 
2251C  Initial Certification- RO Role 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
The RO will make a determination on the CMHCs request to be a participant in the 
Medicare program. The RO will evaluate the information and recommendation received 
from the SA regarding a CMHCs initial certification application including whether or 
not PHS are being provided; either agree or disagree with the SA recommendation for 
initial certification or denial based upon provider agreement requirements; and notify the 
applicant of the its decision. The RO will forward a CMS-2007 to the MAC whether the 
applicant is approved or denied for certification. If approved, a CCN and provider 
agreement are issued. 
 
2251D - Facility Alleges it is Provider-Based 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
A hospital may provide partial hospitalization services either through its outpatient 
department or through a hospital based CMHC. The hospitals ability to bill for partial 
hospitalization through its outpatient departments became effective December 22, 1987, 
under 1861(ff) of the Act. Hospital outpatient departments do not need to qualify as 
CMHCs to initially provide, or continue to provide, partial hospitalization services. The 
hospital may also elect to operate a certified facility as a component of its hospital. 
 
Although the statute does not preclude CMS approval of hospital-based CMHCs, an 
entity, for the purposes of providing partial hospitalization services, can qualify under 
Medicare either as a hospital outpatient department or a CMHC that is hospital- based. 
An entity does not have the option to qualify as both a hospital outpatient department 
and a hospital-based CMHC to provide partial hospitalization services. Allegations of 
provider-based, whether alleged initially by the applying CMHC, or subsequent to 
CMS approval as a CMHC, will be developed using the guidelines contained in 
2004. 
 
2251E  Voluntary Termination 
(Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
A Medicare participating CMHC may voluntarily terminate its provider agreement at any 
time. The SA will follow the guidance in SOM 3046, 3047, and 3048 in processing the 
termination. 
 
2251F - Involuntary Termination  (Rev. 197, Issued: 01-10-20, Effective: 01-10-20, Implementation: 01-10-20) 
 
A CMHCs provider agreement will be involuntarily terminated if the CMHC is not 
in compliance with the CoPs or does not provide PHS. The SA will follow the 
guidance in SOM 3005, 3005A, 3005B and 3005D in processing the termination. 
All CMHCs must comply with the CoPs. 
 
 
Critical Access Hospitals (CAHS) 
 
2254 - CAHS (Critical Access Hospitals) 
 
(Rev. 1, 05-21-04) 
 
2254A - Statutory Citation 
 
(Rev. 1, 05-21-04) 
 
Section 4201 of the Balanced Budget Act of 1997, Public Law 105-33, amended 1820 of 
the Social Security Act and created the Medicare Rural Hospital Flexibility Program 
(MRHFP).  The program allows for the creation of critical access hospitals and is designed 
to promote rural health planning, network development, and improve access to health 
services for rural residents of the State. The program is available in any State having rural 
facilities and which chooses to set up such a program and submits an acceptable State plan 
to CMS. 
 
2254B - Regulatory Citation 
 
(Rev. 1, 05-21-04) 
 
The Conditions of Participation (CoPs) for Critical Access Hospitals are found in the Code 
of Federal Regulations at 42 CFR Part 485 subpart F. 
 
2254C - Submission of a State Plan 
 
(Rev. 1, 05-21-04) 
 
States who are interested in establishing CAHS must submit an application to the Regional 
Administrator of the CMS Regional Office responsible for oversight of Medicare and 
Medicaid in the State.  An official of the State must sign the application.  The application 
must express the States interest in developing a MRHFP.  There are no Federal forms and 
no set format for the submission of the State plan.  The State plan should designate 
facilities in the State that qualify for critical access hospital status.  There is no statutory or 
regulatory requirement for CMS to review changes or updates to any State plan 
subsequent to the initial review and acceptance by CMS. 
  2254D - Requirements for Critical Access Hospitals 
 
(Rev. 1, 05-21-04) 
 
A critical access hospital is a facility that is designated as a CAH by the State in which it 
is located and meets the following criteria: 
 
  Meets the Conditions of Participation found at 42 CFR Part 485 subpart F; 
 
  Is a rural public, non-profit or for-profit hospital; or is a hospital that was closed 
within the previous ten years; or is a rural health clinic that was downsized from a 
hospital; 
 
  Is a facility located in a State that has established a State plan with CMS for the 
Medicare Rural Hospital Flexibility Program; 
 
  Is located more than a 35-mile drive from any other hospital or CAH (in 
mountainous terrain or in areas with only secondary roads available, the mileage 
criterion is 15 miles); or is certified by the State in the State plan as being a 
necessary provider of health care services to residents in the area; 
 
  Makes available 24-hour emergency care services 7 days per week; 
 
  Provides not more than 15 beds for acute (hospital level) inpatient care.  An 
exception to the 15-bed requirement is made for swing-bed facilities, which are 
allowed to have up to 25 inpatient beds that can be used interchangeably for acute 
or SNF-level care, provided that not more than 15 beds are used at any one time 
for acute care; 
 
  Provides an annual average length of stay of 96 hours per patient for acute care 
patients;  
 
NOTE:  An exception has been made by CMS for hospice admissions to a CAH.  The 
hospice may contract with a CAH to provide the hospice hospital benefit.  Reimbursement 
from Medicare is made to the hospice.  The CAH may dedicate beds to the hospice but the 
beds must be counted as part of the allowable number of CAH beds.  The hospice patient 
does not contribute to the 96-hour annual average length of stay computation.  The 
hospice patient can be admitted to the CAH for any care involved in their treatment plan 
or for respite care.  The CAH negotiates reimbursement through an agreement with the 
hospice. 
 
2255 - SA Procedures for CAH Approval 
 
(Rev. 1, 05-21-04) 
 
A CAH must be surveyed for compliance with the CoPs in 42 CFR Part 485 subpart F, 
and compliance with the specific CAH SNF requirements specified by 42 CFR 485.645(d)  if it has or is requesting swing-bed approval. 
 
2255A - CAH Applications 
 
(Rev. 1, 05-21-04) 
 
When a facility contacts the SA to apply for Medicare participation as a CAH, the SA 
sends a letter to the CAH, see (Exhibit 134) Transmitting Materials to Critical Access 
Hospitals. 
 
A current Medicare provider who is requesting a change of status to a CAH sends an 
amended Form CMS-855A to the FI with specific information required by the FI. 
 
Within 30 days, the intermediary will notify the SA indicating if the Form CMS-855A was 
approved or not approved.  The State survey agency verifies that the facility has been 
properly designated as a CAH by the State government entity responsible for CAH 
designation prior to forwarding the application to the RO. 
 
2255B - Pre-Survey Activity 
 
(Rev. 1, 05-21-04) 
 
The SA follows the procedures outlines in Appendix W,  Survey Protocol for CAH 
Providers.  The SA verifies requirements in the CAH CoPs in 42 CFR 485.608, 485.610, 
and 485.612 from facility files and any other documentation available at its office.  If the 
prospective CAH has swing-bed approval, the SA determines that the swing-bed approval 
is current.  
 
2255C - Arranging a CAH Survey 
 
(Rev. 1, 05-21-04) 
 
After the RO has authorized a survey, the SA follows the procedures outlined in Appendix 
W, Survey Protocol for CAH Providers.  All CAH surveys are unannounced surveys. 
 
2255D - Onsite  Survey  Activity 
 
(Rev. 1, 05-21-04) 
 
The SA follows the guidelines for the survey process in Appendix W. 
 
2255E - Preparing a Statement of Deficiencies 
 
(Rev. 1, 05-21-04) 
 
The SA uses the Statement of Deficiencies and Plan of Correction, Form CMS-2567, 
when citing deficiencies, and refers to Exhibit 7A, Principles of Documentation, for  procedural guidance.  The SA sends the completed Form CMS-2567 to the facility.  If 
there are deficiencies cited, the SA sends a letter, see Exhibit 151, Request for a Plan of 
Correction Following an Initial CAH Survey.  If there are swing-bed deficiencies, a 
separate Form CMS-2567 must be prepared. 
 
2256 - RO Procedures for CAH Approval 
 
(Rev. 1, 05-21-04) 
 
A prospective CAH must be surveyed by the SA and be in compliance with the CoPs for 
CAHS at 42 CFR Part 485 subpart F, before it can be approved for participation in 
Medicare as a CAH provider.  The change from hospital to CAH is considered a change in 
status.  A new provider agreement is not needed unless there is a change in ownership 
(CHOW) without the assumption of debt. 
 
2256A - Verification Criteria 
(Rev. 143, Issued: 07-31-15, Effective: 07-31-15, Implementation: 07-31-15)  
 
If the provider is a hospital, CAH verification requires that the RO review the facility file 
to determine if the prospective CAH is in compliance with the hospital CoPs in 42 CFR 
Part 482 at the time it made application for designation as a CAH (see 42 CFR 485.612).  
If the provider is a closed hospital or a downsized hospital, it is not necessary that they 
meet hospital CoPs at the time of application or on conversion. 
 
The RO will reverify compliance with 42 CFR 485.610(a) and (b) and has primary 
responsibility to verify compliance with 42 CFR 485.610(c) and (d). 
 
NOTE: A hospital applying for CAH certification should not be surveyed until after the 
RO determined that the applicant is compliant with the CAH location and distance 
requirements. If the survey is conducted prior to the RO making a determination regarding 
the applicants compliance with the location and distance requirements, and the RO finds 
that the applicant is noncompliant, the application must be denied.  The applicant may 
submit a reapplication for CAH certification in connection with the initial enrollment 
application  using the guidance in Chapter 2 of the SOM, 2005A2. 
 
Rural location  
 
Among other requirements, pursuant to 42 CFR 485.610(b), all CAH applicants and 
existing CAHs, including necessary provider CAHs, must either be:  
 
  Located in a rural area; or  
  Treated as rural in accordance with 42 CFR 412.103 
 
in order to be eligible for CAH designation and certification.   
 
Only the CMS Regional Office makes the determination whether a CAH applicant or 
existing CAH meets the rural location requirement, following the instructions below.   However, State Survey Agencies (SA) may wish to make informal assessments prior to 
conducting a survey.  If the SAs informal assessment suggests the CAH applicant or 
existing CAH is not rural, it should consult with the RO before conducting a survey. 
 
  Located in a rural area  i.e., outside a Metropolitan Statistical Area (MSA)   
 
Under 42 CFR 485.610(b)(1)(i), a rural area is any area that is outside a MSA, as defined 
by the Federal Office of Management and Budget (OMB).  In making a determination 
regarding the rural status of a CAH, the CMS RO first consults the latest OMB MSA 
delineations that have been adopted by CMS. 
 
OMB conducts a comprehensive review of its MSA delineations once a decade and also 
conducts periodic updates between decennial censuses based on Census Bureau data.  
When OMB releases revised statistical area delineations, typically CMS adopts the new  
delineations in the next hospital Inpatient Prospective Payment System (IPPS) rule, which 
is usually proposed in April of each year, published as a final rule in August and effective 
on October 1st following the final rule publication date.  If an IPPS final rule has been 
released during a time when OMB has not released revised statistical area delineations, the 
most recently-released OMB delineations adopted by CMS remain in effect.  Accordingly, 
the RO must consult the MSA delineations used for the purpose of the final IPPS rule that 
is in effect at the time of: 
 
   The Medicare Administrative Contractors (MAC) determination that a 
hospital has submitted a complete application to convert to CAH certification; 
or 
  At the time of the ROs recertification review of an existing CAH.   
 
The most recent final IPPS rules can be found on CMS Acute Inpatient PPS webpage:  
 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/index.html 
  
ROs may use the following instructions to locate the OMB MSA delineations in effect at 
the applicable time for a rural location determination: 
 
1. Go to the Acute Inpatient PPS webpage noted above. 
2. Select the link for the IPPS final rule in effect at the applicable time for the initial 
applicant or at the time of the recertification decision for an existing CAH.  For 
example, if a CAH is up for recertification and the RO is evaluating the CAHs 
compliance with the rural location requirement on February 1, 2016, the most recent 
OMB MSA delineations adopted by CMS would be those effective October 1, 2015 
and the RO would select FY 2016 IPPS Final Rule Home Page from the list of IPPS 
rules on the left-hand column.  On the other hand, if the RO is evaluating the existing 
CAHs compliance on September 10, 2015, it would select the FY 2015 IPPS Final 
Rule Home Page, since the FY 2016 rule would not go into effect until October 1, 
2015.  3. Select the link for final rule data files.  For example, on the FY 2015 IPPS Final Rule 
Home Page, select the link titled FY 2015 Final Rule Data Files. 
4. In the Downloads section at the bottom of the page, select the link for the County to 
CBSA Crosswalk File. 
5. Select the Excel file.  For example, for the FY 2015 IPPS final rule, select the file 
titled CBSAtoCountycrosswalk_FY15_FR.xlsx. 
6. Search for the county in which the CAH is located.  If the IPPS rule has adopted 
revised OMB statistical delineations, the revised information will be found in column 
G, which is titled, New CBSA" (Blanks are Rural).  Column G includes the CBSA 
code for each county.  If the cell is blank, the county is a rural county.  If all of 
Column G is blank, this means that the final IPPS rule did not include adoption of 
revised OMB statistical delineations, and that the delineations from a prior final rule 
remain in effect. 
 
  Even if the existing CAH or CAH applicant is located outside an MSA and 
therefore is in a rural area, it is also necessary to determine that it is also not: 
 
  Located in an area that has been recognized as urban in accordance with 42 
CFR 412.64(b), excluding 412.64(b)(3);    
  Classified as an urban hospital in accordance with 42 CFR 412.230(d) (NOTE: 
42 CFR 412.230(d) became 412.230(d) in 2001); or 
  Redesignated to an adjacent urban area in accordance with 42 CFR 412.232. 
 
Financial staff in the RO should be able to provide information on whether the 
CAH applicant falls in one of the above three categories, since 42 CFR Part 412 
are regulations developed primarily for payment purposes. 
 
  Located within an MSA, but treated as rural  
 
Even if the CAH applicant is located in an MSA, it may nevertheless qualify to be 
treated as rural if it is a hospital that has been reclassified as rural in accordance with 
42 CFR 412.103, i.e., it was reclassified based on: 
 
  Being located in a rural census tract of a MSA per the most recent version of 
the Goldsmith Modification or the Rural-Urban Commuting codes, as 
determined by the Office of Rural Health in the Health Resources and Services 
Administration. (See 
http://www.hrsa.gov/ruralhealth/policy/definition_of_rural.html);  
 
  Or 
 
  It would qualify as a rural referral center or a sole community hospital if it 
were located in a rural area; 
 
Or 
    It is located in an area designated under any State law (including State 
regulation) as a rural area, or has been designated as a rural hospital under 
State law (including regulation). 
 
Rural reclassifications are handled by the CMS RO Office of Financial Management.  RO 
survey and certification staff should consult with their financial management counterparts 
to determine whether a reclassification has been made that would permit a CAH applicant 
or existing CAH to be treated as rural.  
 
In the case of an initial application for CAH status by a hospital, the application must 
be denied if the hospital applicant is located within an MSA or has not been reclassified in 
a manner that allows it to be treated as rural.  If the  applicant subsequently succeeds in 
being reclassified as rural, it may submit a reapplication for CAH certification in 
connection with the initial enrollment application  using the guidance in Chapter 2 of the 
SOM, 2005A2  on or after the effective date of its reclassification . If the hospital was 
surveyed for compliance with the CAH CoPs as part of its prior denied application, it must 
nevertheless be surveyed again; however, this survey does not require an on-site visit if 
the hospital is otherwise in substantial compliance with the CAH CoPs. (NOTE:  This 
should be a rare occurrence as a hospital applying for CAH certification should not be 
surveyed until the RO has determined that the applicant is in compliance with the CAH 
location and distance requirements). The effective date of its CAH conversion must be no 
earlier than the date when the applicant demonstrates compliance with all requirements to 
be certified as a CAH. 
 
In the case of an existing CAH that is being recertified, the RO first determines 
whether the CAH is outside of an MSA, using the OMB MSA delineations adopted by 
CMS and in effect at the time the RO is processing the CAHs recertification.  If the CAH 
is no longer outside an MSA, the RO must consult with the RO Office of Financial 
Management to determine whether there is a reclassification in effect that permits the 
CAH to be treated as rural. 
 
If the existing CAH previously was outside an MSA, but is now in an MSA and has not 
been reclassified as rural, the CAH may continue to retain its CAH status up to two years 
after the effective date of CMSs adoption of the OMB MSA delineations that changed the 
CAHs rural status.  The CAH is responsible at all times for ensuring that it meets the 
requirement at 485.610(b) to be considered rural.  Therefore, in order to continue 
participating in the Medicare program, during the two-year grace period the CAH is 
expected either to successfully be  reclassified to be treated as rural or to have completed 
conversion to a Medicare-certified hospital, including demonstrating compliance with the 
hospital CoPs at 42 CFR Part 482.  Note that a recertification review of the CAHs status 
and location by the RO is triggered any time: 
 
  An SA conducts a full survey of a CAH, whether for recertification of a non-
accredited CAH, for a validation survey of a deemed status CAH, or when following 
up on a prior complaint survey and the RO requires a full survey; or 
    An accrediting organization reaccredits a deemed status CAH and recommends to the 
RO continued deemed status. 
 
If the recertification review of the CAH takes place more than two years after the effective 
date of the CMS adoption of revised OMB MSA delineations that resulted in the CAHs 
loss of rural status and the CAH has not been reclassified to be treated as rural, the CAH is 
substantially noncompliant with the CAH Status and Location CoP (485.610) and the RO 
takes action to terminate the CAHs Medicare agreement. 
 
Examples: 
 
  Example 1:  The RO is conducting a recertification review of a CAH in January, 2016.  
When CMS initially certified the CAH, it determined that the CAH was located 
outside of an MSA.  However, for the purposes of this example, the OMB MSA 
delineations that were adopted by CMS and effective October 1, 2014 resulted in the 
CAH being located within an MSA.  The CAH had a maximum of two years  up to 
and including October 1, 2016 - to retain its CAH certification status.  However, the 
CAH did not seek reclassification to be treated as rural.  After conducting its January 
2016 review, the RO would notify the CAH that it no longer satisfies the CAH rural 
status requirement and could remain certified as a CAH only until October 1, 2016.  
The CAH would then have 10 months to either be reclassified as rural or to complete 
conversion to CMS-certified hospital status in order to avoid termination of its 
Medicare agreement. 
 
  Example 2: The CAH in Example 1 was not reviewed for recertification until January 
2017, a date more than two years after the effective date of its changed MSA status.  
Additionally, the CAH had not been reclassified as rural and had not converted to 
hospital certification.  In this situation, the CMS RO would determine that the CAH 
does not satisfy the CAH rural status requirement and would take action to terminate 
the CAHs Medicare agreement.  
 
  Example 3:  For the purposes of this example only, revised OMB MSA delineations 
were released in May 2014, proposed for adoption by CMS as part of the IPPS rule in 
April 2015, adopted by CMS August 8, 2015, and became effective October 1, 2015.  
Furthermore, a MAC determined that an initial CAH applicants application was 
complete and could be recommended to the RO and SA for approval as of June 5, 
2015, contingent upon the CAH being certified by CMS.  Also the CAH applicant was 
recommended for deemed status by a CMS-approved Medicare CAH accreditation 
program, with an August 15, 2015 accreditation effective date.  In this case, the RO 
would use the OMB MSA delineations that CMS had most recently adopted as of June 
5, 2015, i.e., those adopted by CMS effective October 1, 2014, in making its 
determination about rural status, and found that the CAH was outside an MSA and 
certified it as a CAH effective August 15, 2015.  The RO does this even though OMB 
released more recent delineations in May 2014 and CMS has already adopted a rule 
incorporating the later OMB MSA delineations.  Since the adoption of the later 
delineations is not effective until October 1, 2015, the RO must use the MSA 
delineations previously adopted by CMS and applicable on June 5, 2015.   
  Example 4:  Finally, using the CAH in Example 3, the CAH is now located inside an 
MSA based on revised OMB MSA delineations adopted by CMS effective October 1, 
 
2015.   As a result, the CAH no longer meets the rural location requirement as of 
October 1, 2015, but may retain its CAH status until October 1, 2017.  Note that in this 
case the CAH is not due for reaccreditation and recertification until August 2018, 
which is after the end of the grace period.  If the CAH has neither been successfully 
reclassified as rural nor converted to a hospital by October 1, 2017, the RO would take 
action to terminate the CAHs Medicare agreement. 
 
In all of the above examples, the CAH has primary responsibility for monitoring changes 
in its rural status resulting from CMSs adopted revised OMB MSA delineations, and 
taking appropriate action if it loses its rural status on the basis of the revised delineations. 
 
Necessary Provider Status and Rural Reclassification 
 
Necessary provider certification only provides an exemption from the CAH distance 
requirements relative to other CAHs and hospitals.  Necessary provider CAHs are still 
required to meet the rural location requirement; therefore, if a necessary provider CAH is 
located within an MSA as a result of a change in the OMB MSA delineations adopted by 
CMS, it must follow the same procedures noted above as any other CAH. 
 
Location relative to other facilities or necessary provider certifications: 
 
In addition, the regulations at 42 CFR 485.610(c) specify that one of the following 3 
minimum driving distances from other facilities requirements must be met: 
 
  35-Mile Distance: The CAH must be located more than a 35-mile drive from 
any hospital or  other CAH; or 
 
  15-Mile Distance: In the case of mountainous terrain or in areas with only 
secondary roads available, the CAH must be located more than a 15-mile 
drive from any hospital or other CAH; or 
 
  No Distance Requirement: In the case of a CAH that was designated by the 
State as being a necessary provider of health care services to residents in the 
area before January 1, 2006, there is no minimum distance requirement. 
 
In determining whether a currently certified CAH or a CAH applicant meets the location 
requirements at 485.610(c), the proximity of IHS/Tribal hospitals or CAHs and non-
IHS/Tribal hospitals or CAHs to each other is not considered. 
 
The following examples clarify how determinations are to be made when IHS or Tribal 
hospitals or CAHs are in the vicinity of non-IHS or non-Tribal hospitals or CAHs: 
 
  Example 1: Hospital A is seeking CAH certification and is a 10-mile drive from 
Hospital B, an IHS hospital.  Hospital C is the next nearest hospital/CAH and is a 42- mile drive from Hospital A. The distance to Hospital B is not considered; Hospital A 
meets the minimum distance to another CAH or hospital requirement. 
 
  Example 2: CAH A is a tribal facility that is being reviewed as part of the 
recertification process.  It is a 17-mile drive from a non-tribal/non-IHS CAH (CAH B).  
It is also a 75-mile drive from an IHS hospital (Hospital C).  The distance to CAH B is 
not considered; CAH A continues to meet the minimum distance to another CAH or 
hospital requirement. 
 
  Example 3: Hospital A is a tribal hospital seeking CAH certification and is a 33-mile 
drive along primary roads to an IHS hospital, Hospital B.  It is also a 50-mile drive to 
Hospital C, a non-IHS/non-tribal hospital.  The distance to Hospital B is considered; 
Hospital A does not meet the minimum distance to another CAH or hospital 
requirement. 
 
If a CAH is located on an island and the location meets the following characteristics, the 
CAH is considered to be in compliance with the distance requirements relative to other 
hospitals and CAHs under 485.610(c): 
 
  The island is entirely surrounded by water; 
  The CAH is the only hospital or CAH on the island; and  
  The island is not accessible by any roads. 
 
CAHs located on islands that meet the criteria above are still required to comply with the 
rural location requirement under 485.610(b). 
 
In demonstrating that it meets the standard for more than a 35-mile drive, a CAH applicant 
must document that there is no driving route from the applicant to any other CAH or 
hospital that is 35 miles or less in length. 
 
Application of the more than 15-mile drive standard, based on mountainous terrain 
 
Slope and ruggedness of the terrain around the CAH, together with absolute altitude (the 
distance above sea level), determine many of the fundamental characteristics of 
mountainous terrain.1  However, being located at a high elevation does not, in and of 
itself,  constitute mountainous terrain, nor does being located at the foot of a mountain 
or where mountains can be viewed.  Further, the absolute altitude required to constitute 
mountainous terrain will vary in different regions.  For example, the altitude of the 
Appalachian Mountains is considerably lower than that of the Rocky Mountains, yet the 
slope and ruggedness of the terrain in many portions of the Appalachians is mountainous.  
Furthermore, roads passing through mountainous terrain are characterized by certain 
typical engineering features.  For the purposes of determining a CAHs eligibility for the 
15-mile drive standard based on mountainous terrain, the roads on the travel route(s) to 
hospitals or other CAHs must meet the following criteria: 
                                                 
1 United Nations Environment Programme World Conservation Monitoring Centre. (2002). Mountain 
Watch. Retrieved August 11, 2010, from http://www.unep-wcmc.org/mountains/mountain_watch/pdfs/.   
  Over 15 miles of the roads on the travel route(s) from the CAH to any hospital or 
another CAH must be located in a mountain range, identified as such on any 
official maps or other documents prepared for and issued to the public;   
and 
 
  Since being located within a mountain range in and of itself does not  mean that the 
drive to any other hospital or CAH includes travel through mountainous terrain, the 
roads on the travel route(s) from the CAH to any other hospital or CAH must have 
either of the following characteristics: 
 
  Extensive sections of roads with steep grades (i.e., greater than 5 percent), 
continuous abrupt and frequent changes in elevation or direction, or any 
combination of horizontal and vertical alignment that causes heavy vehicles to 
operate at crawl speeds for significant distances or at frequent intervals.2  
(Horizontal alignment refers to the straightness of the roadway, vertical 
alignment refers to the roadways flatness, and crawl speed is the speed at 
which a truck has no power to accelerate on long, steep grades.3,4  Thus, roads 
in mountainous terrain are commonly described as winding and steep);  
or 
 
  Be considered mountainous terrain by the State Transportation or Highway 
agency, based on significantly more complicated than usual construction 
techniques that were originally required to achieve compatibility between the 
road alignment and surrounding rugged terrain.  For example, because the 
changes in elevation and direction are abrupt in mountainous terrain, roadbeds 
may require frequent benching, side hill excavations, and embankment fills. 5 
 
A letter from the State Transportation or Highway agency specific to the travel route(s) in 
question is required to support the claim of mountainous terrain based on either of these 
sets of road characteristics. 
 
It is not uncommon for there to be roads (or sections of roads) through mountainous areas 
that do not meet the criteria for mountainous terrain.  A CAH would qualify for 
application of the mountainous terrain criterion if there is a combination of mountainous 
and non-mountainous terrain between it and any other hospital or CAH, so long as there is 
no route to any hospital or other CAH with 15 or fewer miles of roads in mountainous 
terrain.  When calculating the mountainous terrain travel distance to any hospital/other 
CAH, subtract the total distance represented by those sections of the travel route that are 
                                                 
2 Mannering, F. L., Washburn, S. S., & Kilareski, W. P. (2009). Principles of Highway Engineering and 
Traffic Analysis. Hoboken, NJ:  John Wiley and Sons, Inc 
3 Highway Capacity Manual: 2000 (U. S. Customary Units) by Transportation Research Board (Dec. 
2000). p 23-9.
 
4 Donnell, E. T., Ni, Y., Adolini, M., & Elefteriadou, L. (2001). Speed prediction models on two-lane rural 
highways. Transportation Research Record, 1751, 44-55.   
5 Mannering, F. L., Washburn, S. S., & Kilareski, W. P. (2009). Principles of Highway Engineering and 
Traffic Analysis. Hoboken, NJ:  John Wiley and Sons, Inc. 
  not considered mountainous terrain.  For example, if the route to the nearest hospital 
consisted of 12 miles in mountainous terrain, followed by 5 miles in non-mountainous 
terrain, followed by 4 miles in mountainous terrain, then the requirement for a total of 
more than 15 miles would be met (12 miles plus 4 miles  or 21 miles minus 5 miles  
yield 16 total miles of mountainous terrain). 
 
Application of the more than 15-mile drive standard, based on secondary roads  
 
To be eligible for the lesser distance standard due to the secondary road criteria under 
485.610(c) the CAH must document that there is a drive of more than 15 miles between 
the CAH and any hospital or other CAH where there are no primary roads.  A primary 
road is: 
 
  Any US highway, including any road: 
  In  the National Highway System, as defined in 23 US Code 103(b); or 
o
  In the Interstate System, as defined in US Code 103(c); or 
o
  Which is a US-Numbered Highway (also called US Routes or US 
o
Highways) as designated by the American Association of the State Highway 
and Transportation Officials (AASHTO), regardless of whether it is also part 
of the National Highway System; 
 
All US highways are readily identified via signage along the roads and on maps by the 
presence of US or I above the highway number, with the letters and number 
appearing on a distinctive, uniform shield background that is called the six point 
shield, with five points above and one below.   Note:  Although the National Highway 
System and the U.S. Numbered Highway system largely overlap, they are not 
identical.  According to the American Association of the State Highway and 
Transportation Officials (AASHTO), which is responsible for designation of roads in 
the U.S. Numbered Highway system, the system is intended to facilitate the movement 
of interstate traffic in two or more States with the use of uniform markings.6 
 
Given the role all US highways are intended to play in interstate commerce, they are, 
by definition, primary roads.   
 
OR 
 
  A numbered State highway with 2 or more lanes each way;  
 
OR 
 
  A road shown on a map prepared in accordance with the U.S. Geological Surveys 
Federal Geographic Data Committee (FGDC) Digital Cartographic Standard for 
Geologic Map Symbolization as a primary highway, divided by median strip. 
 
                                                 
6 AASHTO Special Committee on U.S. Route Numbering. Retrieved June 17, 2014, from:   
http://route.transportation.org/Documents/HO1_Policy_Establ_Develop_USRN.pdf
  A CAH may qualify for application of the secondary roads criterion if there is a 
combination of primary and secondary roads between it and any hospital or other CAH, so 
long as more than 15 of the total miles from the hospital or other CAH consists of areas in 
which only secondary roads are available.  To apply the secondary roads criterion, 
measure the total driving distance between the CAH and each hospital or CAH located 
within a 35-mile drive and subtract the portion of that drive in which primary roads are 
available.  If the result is more than 15 miles for each drive to a hospital or CAH facility, 
the 15-mile criterion is met. 
 
The RO will review Web-based map servers, such as Google Maps, or NationalAtlas.gov 
for example, to determine whether the provider meets the requirements of 42 CFR 
485.610(c).  The RO will also review any documentation the provider may submit to 
demonstrate that it meets either the mountainous terrain or secondary roads criterion of 
485.610(c), but such documentation must satisfy the requirements discussed above.  For 
example, CMS does not consider any issues raised by CAH applicants or other parties 
concerning the physical features of any specific US highway, or portion thereof, when 
making a CAH location determination.  Therefore, documentation submitted by the 
applicant indicating that a particular portion of a US highway has numerous curves, or a 
weight limitation, or narrow shoulders, etc. would not affect the ROs determination that 
the highway is a primary road. 
 
2256B - Notification 
 
(Rev. 1, 05-21-04) 
 
When the facility is found to be in full compliance with the CoPs in 42 CFR Part 485, 
Subpart F, or has submitted an acceptable Plan of Correction, the RO notifies the facility 
in writing by sending letter, see Exhibit 150, CAH Approval Notification, stating the 
facility has been approved for participation.  A copy of the notice letter is sent to the FI 
and SA.  Do not issue the letter until the facility is in compliance with all the CoPs. 
 
2256C - Effective Dates 
 
(Rev. 1, 05-21-04) 
 
After the RO has reviewed and approved the SA recommendation for Medicare 
participation, the effective date for participation by a CAH will be one of the following:  
 
  The last date of the initial survey by the SA, provided the prospective CAH is in 
full compliance with the CAH CoPs on that date; or  
 
  The date that the prospective CAH submits an acceptable plan of correction to the 
SA. 
 
2256D - RO Processing Complaints Against a CAH 
 
(Rev. 1, 05-21-04)   
When the RO or SA receives a complaint against a CAH regarding the CoPs in  
42 CFR Part 485 subpart F, including the SNF requirements for a swing-bed CAH, the RO 
follows the normal complaint process for non-accredited hospitals.  
 
2256E - RO Processing Denials or Terminations of a CAH 
 
(Rev. 1, 05-21-04) 
 
When the RO processes a denial or termination of a CAH, it follows the normal 
procedures that apply to Medicare-participating hospitals.  For CAH denials, the RO uses 
a letter, see Exhibit 149, CAH Denial for Medicare Participation Letter; for CAH 
terminations use a letter, see Exhibit 152, CAH Termination Letter. 
 
2256F - Relocation of CAHs With a Grandfathered Necessary Provider 
Designation 
 
(Rev. 32, Issued: 01-18-08, Effective: 09-07-07, Implementation: 09-07-07) 
 
The intent of the CAH program is to keep hospital-level services in rural communities, 
thereby ensuring access to care, through provision of reimbursement on a more favorable 
basis than that available to participating hospitals.  Therefore, CAHs are required to satisfy 
criteria designed to assure that they are located in rural areas and that there are no other 
hospitals or CAHs close by. 
 
Prior to January 1, 2006, States were able to waive the distance requirement (the 
requirement that the facility be 35 miles from other hospitals or CAHs) by designating a 
facility as a necessary provider CAH.  Section 405(h)(2)(B) of the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 changed the statute.  As of January 1, 
2006, States are no longer permitted to designate a facility as a necessary provider CAH, 
but existing necessary provider CAHs were grandfathered.  The regulations at 42 CFR 
485.610(d) specify limits on the ability of a grandfathered CAH to relocate and still retain 
its grandfathered status.  The regulation permits such CAHs to relocate, so long as the 
CAH remains essentially the same provider and continues to ensure access to care in the 
same rural service area.  Specifically: 
 
485.610(d) Standard:  Relocation of CAHs that have a necessary provider 
designation. 
 
A CAH that has a necessary provider designation from the State that was in effect prior to 
January 1, 2006, and relocates its facility after January 1, 2006, can continue to meet the 
location requirement of paragraph (c) of this section based on the necessary provider 
designation only if the relocated facility meets the requirements as specified in paragraph 
(d)(1) of this section. 
 
(1) If a necessary provider CAH relocates its facility and begins providing services 
in a new location, the CAH can continue to meet the location requirement of  paragraph (c) of this section based on the necessary provider designation only if 
the CAH is in its new location-- 
 
(i)  Serves at least 75 percent of the same service area that it served prior to 
its relocation; 
 
(ii) Provides at least 75 percent of the same services that it provided prior 
to the relocation; and 
 
(iii)Is staffed by 75 percent of the same staff (including medical staff, 
contracted staff, and employees) that were on staff at the original 
location. 
 
(2  If a CAH that has been designated as a necessary provider by the State begins 
providing services at another location after January 1, 2006, and does not meet the 
requirements in paragraph (d)(1) of this section, the action will be considered a 
cessation of business as described in 489.52(b)(3). 
 
Apply the guidance below in determining whether the regulatory requirements have been 
met. 
 
General Considerations in Any Relocation 
 
  Burden of Proof:  The CAH bears the burden of proof in demonstrating that its 
relocation satisfies the regulatory standards. 
 
  Basis for Necessary Provider Designation:  As explained when the regulation at 
42 CFR 610(d) was first published, the CAH is expected to continue to provide 
services based on the criteria that the State used when initially determining that 
the CAH was a necessary provider.  For example, if the determination was based 
on the CAH being located in a health professional shortage area (HPSA), then the 
relocated CAH must continue to be located in a HPSA.  (See 70 FR 23453 and 70 
FR 47472.)  The CAH bears the burden of providing documentation from the 
State indicating what the original basis of the States necessary provider 
determination was, and that the relocation will not have any impact on continued 
conformity of the CAH to the original decision criteria. 
 
  Renovation or Expansion:  Renovation or expansion of a CAHs existing building 
or addition of building(s) on the existing main campus of the CAH is not 
considered a relocation (unless a CAH previously undertook a relocation without 
receiving the necessary RO approval).  There is no change to its CAH designation 
and, therefore, no need for the RO to make any determination on its continued 
CAH designation. 
 
  All New Facilities:  All newly constructed necessary provider CAH facilities are 
considered relocated facilities.  This includes construction of a new facility that 
replaces the existing CAH main campus, even when on the same site as the  original building.  (See 70 FR 47472.) (See discussion at 70 FR 47472.) 
 
  Relocation Without Necessary Provider Designation:  If a CAH relocates and 
meets, at the new location, all of the CoPs found at 42 CFR 485 Subpart F 
(including location in a rural area as required at 485.610(b) and distance from 
other hospitals or CAHs as required at 485.610(c)), it will qualify for CAH 
designation in the same way as would a new CAH.  However, if it wishes to retain 
its grandfathered necessary provider status, then it must also satisfy the 
requirements at 485.610(d). 
 
  75 Percent Criteria:  The relocated CAH must meet each of the three 75 percent 
criteria found at 42 CFR 485.610(d) (and explained below) in order to maintain its 
grandfathered necessary provider designation after relocation.  We expect that 
CAHs will demonstrate in advance of their relocation the likelihood that they will 
satisfy the criteria.  The discussion below focuses on the evaluation of this 
prospective data.  After the relocation is completed, the CAH must submit 
evidence confirming that it satisfied the criteria. 
 
Listed below are examples of methods necessary provider-designated CAHs could use to 
meet each of the 75 percent criteria at 42 CFR 485.610(d) (1).  The CAHs are free to 
submit documentation employing different methodologies for each criterion, indicating 
how they think both the methodology and supporting evidence document comply with the 
regulatory requirements.  The RO will determine whether the methodology employed is 
supported by the evidence and if the CAH has met the burden of proof necessary to satisfy 
the regulation.  The same methodology should be used by the CAH for both the pre-
relocation attestation and the confirmation after relocation is completed. 
 
Relocation Serves 75 Percent of the Same Service Area 
 
The CAH must present documentation showing why the Service Area projected for the 
relocated CAH will include at least 75 percent of its original service area. 
 
In the absence of special factors that indicate the need for an alternative methodology, in 
order to meet the statutory and regulatory intent of this provision, CMS will compare the 
zip code location of populations currently served by the CAH with the populations in the 
zip codes served by the CAH in its new or proposed new location.  Examples of special 
factors are:  (a)  Statistical anomalies that may occur when each of one or more zip codes 
contains less than 5 percent of the total number of individuals served by the CAH, or (b)  
The presence of major demographic or geographical differences between the old and new 
location (such as an un-bridged river separating the two locations). 
 
 
Example of adequate documentation: 
 
Assume that the CAH identifies the zip codes of its patients from the past year, ranked 
from highest to lowest volume of patients per zip code, and found that it served 200 
patients from the following zip codes:  _______________________________________Patients in New Location________ 
Zip Code    Current Patients    Example #  1        Example #2         Example #3 
Zip code A ............ 80 patients ......  70 ......  70 .........    80 
Zip code B............. 30 patients......  26...    26 ...      30 
Zip code C............. 29 patients......  9......   9...      29 
Zip code D............. 28 patients ...   15...     15       28 
Zip code E............. 24 patients......  0......   24 ...      24 
Zip code F..............  9 patients (4.5%)   30...     0 (Dropped #2)   9 
 
Subtotal (Ex. #1)...  200       150 (75%)  144 
Subtotal (Ex. #2) ...  191          144 (75% of 191) 
Subtotal (Ex. #3)    200 
 
Zip code G        20    26       40 
Zip code H        30    30      60 
 
GRAND TOTAL 200      200    200      300 
 
 
In example #2, zip code F has been dropped at the CAHs request because its percent of 
the current service area is less than 5 percent. 
 
In example #3, the CAH meets the 75 percent requirement.  Even though the number of 
people served from the original location is only 67 percent of the total to be served in the 
new location (200/300), 100% of the volume from the zip codes served in the original 
location will be served in the new location (200/200).  The regulation focuses on whether 
the people in the original location will continue to be served, not whether the CAH 
services are being expanded. 
 
After the CAH has been in operation at the new location for a reasonable period of time 
(e.g., 6 months to 1 year), the CAH must submit evidence to confirm that the 75 percent 
requirement is met as a matter of fact rather than projection. 
 
CMS may lessen the amount of supporting information required in some cases where the 
circumstances and extent of relocation are very simple.  For example, if the CAH 
documents that the new facility is being built on or adjacent to the current facilitys 
campus, then it would be reasonable for the CAH to argue that the relocated CAH by 
virtue of its very close proximity to the original CAH could be assumed to serve the same 
community.  For almost all other cases, more evidence will be required.  Depending on the 
characteristics of the community served by the CAH and the availability of other CAHs or 
hospitals in the region, it is possible that relocations of even a few miles might 
significantly change the CAHs service area. 
 
Seventy-five Percent of the Same Services 
 
In order to meet the 75 percent of the same services standard, the CAH must 
demonstrate that at least 75 percent of the total service lines provided by the CAH at its  original location will continue to be offered at its new location, under generally similar 
terms. 
 
The same services standard under 42 CFR 485.610(d)(ii) does not preclude the CAH from 
adding additional, new services at the new location.  It merely states that the CAH must 
retain 75 percent of the original services offered at its original location prior to relocation. 
 
CMS examines two dimensions to the same services requirement: 
 
  The services lines themselves (e.g., lines of business such as obstetrics), in which 
we compare the number of such lines retained after relocation compared to the 
pre-relocation service array; and 
 
  The scope and availability of such services, in which we seek to understand if 
there are to be any significant reductions in the new location compared to the pre-
location services. 
 
There are a variety of ways in which health care services can be categorized.  The 
regulation does not prescribe a particular service classification taxonomy.  However, the 
CAH must present a breakdown of its services that is sufficiently detailed to enable a pre- 
and post-relocation analysis.  For example, a listing that consisted only of inpatient and 
outpatient services would be too general to permit meaningful analysis.  It would be 
acceptable for a CAH to use the service categories found in the American Hospital 
Association annual hospital survey data, but the CAH can also submit an alternative list of 
services.  In the latter case, the RO will determine whether there is sufficient information 
about the services to make a determination of regulatory compliance.  Whatever service 
classification system the CAH uses to describe the services offered prior to relocation 
must also be used for the services after relocation. 
 
Example 1: 
 
  The CAH originally offered 14 services: 
 
    Outpatient       Inpatient 
 
    Emergency department    General medical/surgical services 
Primary care      Pediatric medical/surgical services 
Pre- & postnatal care    General obstetrics/gynecology 
Outpatient surgery   Orthopedics 
Counseling services    Distinct Part Unit  Psychiatric* 
Well-baby clinic 
Pediatric outpatient services 
Ultrasound 
Mammography 
 
  After relocation the CAH attests that it will retain 12 of those services  
  Retained: 
 
Outpatient         Inpatient 
 
Emergency department      General medical/surgical services 
Primary care         
Pre & postnatal care      General obstetrics/gynecology 
Outpatient Surgery      Orthopedics 
Well-baby clinic         
Pediatric outpatient services 
Counseling services 
Ultrasound 
Mammography 
 
Eliminated: 
 
Outpatient         Inpatient 
 
            Pediatric medical/surgical services 
            Distinct Part Unit  Psychiatric* 
 
  The CAH also proposes to add 7 services: 
 
Added: 
 
Outpatient         Inpatient 
 
MRI 
CT Scanner 
Dietician 
Physical rehabilitation      Distinct Part Unit  Rehabilitation* 
Chemotherapy        Oncology 
 
  Additionally, the retained services are planned and actually are generally 
available under the same terms, e.g., the number of inpatient beds or service 
hours for outpatient clinics are generally the same, etc.  In this scenario the 
CAH demonstrates it will retain over 85 percent of its original services, 
exceeding the 75 percent regulatory requirement.   
 
*NOTE:  Although CAH distinct part units are subject to hospital rather 
than CAH Conditions of Participation, for purposes of 
determining compliance with the 75 percent same services 
standard they must be included in the list of services. 
 
Example 2: 
 
  The CAH originally offered 20 different services.  If the CAH attests it will 
drop 6 services, while adding 6 new and different services, it has not  demonstrated it will retain 75 percent of the same services and would not meet 
the regulatory same service requirement. 
 
Regardless of the number of original services, if the CAH attests it will retain a service, 
but make it available only 20 percent of the time that it was available at the original 
location, then that is not the same service.  If it is available 50 percent or more of the time 
than it was available at the original location, then that service can count toward its 75 
percent of the same services compliance. 
 
In its attestation the CAH should list all the services offered at the CAH at its original 
location at the time of the attestation, including an indication of the quantity or hours the 
outpatient services are available.  It should also list the services and their availability 
planned for the new location. 
 
After the relocation is complete, the CAH must submit confirming evidence that it meets 
the 75 percent same services standard.  The CAH should provide the list of its actual 
services and their availability. 
 
Seventy five percent of the Same Staff (including medical staff, contracted staff, and 
direct employees): 
 
In order to meet the 75 percent of the same staff standard, the CAH must demonstrate 
that 75 percent of the CAHs staff that were at the CAH prior to relocation remains on 
staff after the relocation takes place.  This includes contracted personnel.  For purposes of 
this requirement, contracted staff includes all personnel who regularly work onsite at the 
CAH, whether they are directly contracted by the CAH or whether they are employees of a 
contractor.  At the CAHs option, the CAH may exclude from these calculations all 
contracted employees who work less than halftime on average (or any lesser threshold of 
time the CAH elects (such as 10 hours per week on average).  However, the CAH must 
consistently apply such a threshold in all calculations. 
 
It is not necessary to calculate the 75 percent for each of the 3 types of staff  medical, 
contracted, and direct employees  separately.  For example, a CAH could retain 50 
percent of its medical staff, 40 percent of its contracted staff, but 80 percent of its direct 
employees, and meet the regulatory standard, so long as the retention rate for these 3 
groups combined is 75 percent. 
 
In its attestation, the CAH should provide a list of all staff at the time of the attestation.  It 
must demonstrate how it plans to retain at least 75 percent of its current staff.  Staff who 
are working on a J-1 Visa Waiver Program, National Health Service Corps Federal Loan 
Repayment Program, or National Health Service Corps State Loan Repayment Program 
and whose service limits under the terms of those programs will have expired at the time 
of relocation should not be included when comparing the staff at the old and new 
locations. 
 
Examples of how a CAH could demonstrate in its attestation that it will meet the 75 
percent of the same staff criteria include:   
  Attestation from staff that they expect to continue their current employment or 
contractual relationship with the CAH at the new location; or 
 
  Evidence demonstrating how staff commutes to the CAH would not change 
significantly from the original location to the new location for at least 75 percent 
of staff; or 
 
  Evidence of employment arrangements/contracts continuing with at least 75 
percent of the same staff. 
 
Those CAHs that have difficulty meeting the 75 percent same staff criterion due to 
historically high staff turnover and/or vacancy rates, can provide additional documentation 
explaining the effect of such factors on their ability to satisfy the standard, and whether 
they could meet the standard if the original staff list is adjusted to reflect historical 
turnover.  The CAH must provide evidence, however, that it is actively attempting to 
recruit replacements for the same type of staff as those who have left.  The documentation 
must provide evidence that circumstances beyond the CAHs control rather than the 
relocation of the CAH accounts for the expected greater than 25 percent change in the 
staff roster.  It might not be reasonable to expect a CAH to meet the 75 percent same staff 
standard if it can provide sufficient evidence that it has, for example, a 25 percent historic 
rate of staff turnover.  In addition, to documenting an historically high turnover rate the 
CAH should also provide documentation of efforts it is making to reduce turnover, such as 
evidence of active recruitment efforts, i.e., posting of vacancies, participating in job fairs, 
and evidence of outreach to professional schools and universities.  The CAHs might also 
indicate whether they believe relocation will benefit the facility by decreasing the staff 
turnover rate, including evidence to support this assumption. 
 
Letter of Attestation 
 
Prior to the relocation of a CAH with a necessary provider designation, the CAH should 
submit a letter of intent to the RO.  The CAH would be well-advised to send the letter 
early in the planning stage of its relocation, prior to spending or obligating significant 
funds and resources.  The letter should state that the CAH plans to relocate, i.e., that it 
plans to build a new replacement facility, and must attest that it will continue to be 
essentially the same provider serving the same service area, but in a new facility.  It is 
recommended that the CAH administration contact CMS RO Survey and Certification 
staff prior to preparing the letter of attestation, in order to facilitate communications about 
the standards that a relocated CAH with a necessary provider designation must meet. 
 
To facilitate efficient review by the RO, the Letter of Attestation should include:  
 
  A copy of the CAHs original necessary provider determination from its State 
Office of Rural Health; 
 
  Documentation from the State of how the CAH at the relocation site will continue 
to satisfy the criteria used by the State in the original necessary provider  determination; 
 
  Addresses of both the present location and the future location; 
 
  Documentation that demonstrates how the new facility/location meets the rural 
location requirement at 485.610(b); 
 
  Documentation showing how the CAH will continue to be essentially the same 
provider at the new facility/location, in accordance with 485.610(d); and 
 
  Timetable for the relocation. 
 
The RO will evaluate the letter of attestation and documentation provided by the CAH to 
determine if the planned relocation appears likely to meet the requirements under 
485.610.  The RO will advise the CAH in writing of any additional information that may 
be needed.  The RO will assess the information provided in the attestation letter and notify 
the CAH of its preliminary determination.  The RO will provide preliminary approval of 
the relocation if the information provided by the applicant demonstrates that the proposed 
relocation complies with the regulatory standards at 42 CFR 485.610(b) and (d).  A final 
determination can only be made after the relocation is completed. 
 
Implementation Phase 
 
During the implementation phase, the CAH should notify the RO of any changes to the 
information submitted in its letter of attestation.  The purpose is for the RO to be kept 
apprised of any changes so that the CAH can be informed if the changes do not comply 
with the requirements at 485.610(b) and (d). 
 
After the relocation is completed, if the RO determines the CAH meets all of the 
following criteria: 
 
  Received a preliminary approval for its relocation from the RO; 
 
  No changes have occurred that materially affect its preliminary attestation; 
 
  Holds any required State license at the new location; 
 
  Meets all CoP requirements as determined by an accreditation or SA survey; 
and 
 
  Submits confirming evidence of compliance with the 75 percent criteria (in the 
case of same service area criterion, as noted below, the submission of this 
evidence will need to be submitted at a later point in time as the CAH must see 
patients to conclusively show compliance with the same service area 
requirement, but this should not delay continuation of the provider agreement 
at the new location upon satisfaction of all the other listed criteria); 
  then the RO makes a final determination that the relocated necessary provider CAH will 
be permitted to continue Medicare participation under its original provider agreement as a 
necessary provider CAH. 
 
If the RO determines that the relocated necessary provider CAH does not satisfy the 
regulatory requirements under 485.610(b) and (d), the CAH will be considered to have 
ceased business in accordance with 489.52(b)(3) as of the date that it relocated.  The RO 
will take action to terminate the CAHs provider agreement. 
 
2256G - Co-Location of Critical Access Hospital 
 
(Rev. 49, Issued: 06-12-09, Effective/Implementation: 06-12-09) 
 
It is never permissible for a CAH that is not designated as a necessary provider to be co-
located with another hospital or CAH because of distance requirements it is required to 
meet at 42 CFR 485.610(c).  However, since States had the ability, up until January 1, 
2006, to waive the minimum distance from other hospitals or CAHs requirement for 
CAHs designated as necessary providers, it was technically possible for a necessary 
provider CAH (NPCAH) to be co-located with another hospital or CAH, i.e., share the 
same building or campus as the other facility.  Moreover, prior to the enactment of Section 
405(g) of Pub. L. 108-173, which permits CAHs to operate distinct part inpatient 
psychiatric and/or rehabilitation distinct part units, it was understandable that a State 
Medicare Rural Hospital Flexibility Program (MRHFP) might have allowed co-location of 
a CAH with a necessary provider designation with the specialized services of a psychiatric 
and/or a rehabilitation hospital. 
 
However, as of January 1, 2008, CAHs with a necessary provider designation can no 
longer enter into co-location arrangements with another CAH and/or hospital (72 FR 
66878).  Necessary provider CAHs that had co-location arrangements in effect prior to 
January 1, 2008, may continue these arrangements, as long as the type and scope of 
services offered by the facility co-located with the CAH do not change.  An example of a 
change in type of services would be when a hospital that provides only rehabilitation 
services chooses to provide general hospital acute care services.  An example of a change 
in scope of services would be when a grandfathered necessary provider CAH is currently 
co-located with a 20-bed psychiatric hospital and the psychiatric hospital decides to 
increase the number of beds to 30. 
 
A change of ownership of a CAH participating in a grandfathered co-location arrangement 
will not be considered to create a new, and therefore prohibited, co-location arrangement, 
if, and only if, assignment of the existing provider agreement is accepted by the new 
owner.  In all cases where there is a change of ownership of a grandfathered necessary 
provider CAH and the new owner does not accept assignment of the provider agreement, 
both the CAHs provider agreement and necessary provider designation are terminated as 
part of the former owners provider agreement.  If a grandfathered necessary provider 
CAHs provider agreement is terminated, and the facility seeks a new CAH designation, it 
would be required to meet all CAH requirements, including the minimum distance from 
other hospitals or CAHs.  It would also be prohibited from entering into any co-location  arrangement with a hospital or another CAH. 
 
A change of ownership by a hospital that is co-located with a necessary provider CAH 
does not affect the grandfathered co-location arrangement, regardless of whether the 
hospitals provider agreement is assumed by the new owner or not.   
 
Termination for Noncompliance 
 
Compliance with the co-location requirements of 485.610(e)(1) is determined by the RO.  
A CAH found out of compliance with the requirement is subject to termination of its 
Medicare provider agreement under 489.53(a)(3).  In such cases the CAH is placed on a 
90-day termination track, as outlined in 3012 of the SOM.  During this period, the CAH 
will have the opportunity to come back into compliance and meet all conditions of 
participation (CoPs).  If the CAH corrects the noncompliance situation, by terminating the 
co-location arrangement that led to the non-compliance during this 90-day period, then the 
provider agreement is not terminated. 
 
A facility facing termination of its CAH designation as a result of non-compliance with 
485.610(e)(1) could also continue to participate in Medicare by converting to a hospital, 
assuming that the facility satisfies all requirements for participation as a hospital in the 
Medicare program under the provisions at 42 CFR Part 482.  Under this scenario, the 
CAH would apply to convert back to a hospital and be assigned a new CMS Certification 
Number (CCN) accordingly. 
 
2256H  Off-Campus CAH Facilities 
(Rev. 193, Issued: 09-20-19, Effective: 09-20-19, Implementation: 09-20-19) 
 
Section 42 CFR 485.610(e)(2) requires that if a CAH operates an off-campus provider-
based facility as defined in 413.65(a)(2) (except for a rural health clinic (RHC)) or off-
campus rehabilitation or psychiatric distinct part unit as defined in 485.647, that was 
created or acquired on or after January 1, 2008, then the off-campus facility must meet the 
requirement at 42 CFR 485.610(c) to be more than a 35 mile drive (or a 15 mile drive in 
the case of mountainous terrain or an area with only secondary roads) from another 
hospital or CAH.  Off-campus CAH facilities that were in existence prior to January 1, 
2008, are not subject to this requirement.  The drive to another hospital or CAH is 
calculated from the off-campus facilitys location to the main campus of the other hospital 
or CAH. 
 
If a non-IHS or non-Tribal CAH operates an off-campus provider-based facility, its 
proximity to an IHS or Tribal CAH or hospital is not considered when determining 
compliance with these requirements.  Similarly, if an IHS or Tribal CAH operates an off-
campus provider-based facility, its proximity to a non-IHS or non-Tribal CAH or hospital 
is not considered when determining compliance. 
 
Definitions related to provider-based status are found at 42 CFR 413.65(a)(2): 
    Campus:  means the physical area immediately adjacent to the providers main 
buildings, other areas and structures that are not strictly contiguous to the main 
buildings, but are located within 250 yards of the main buildings, and any other areas 
determined on an individual case basis, by the CMS regional office, to be part of the 
providers campus. 
 
Department of a provider:  means a facility or organization that is either created by, 
or acquired by, a main provider for the purpose of furnishing health care services of 
the same type as those furnished by the main provider under the name, ownership, and 
financial and administrative control of the main provider, in accordance with the 
provisions of this section.  A department of a provider comprises both the specific 
physical facility that serves as the site of services of a type for which payment could 
be claimed under the Medicare or Medicaid program, and the personnel and equipment 
needed to deliver the services at that facility.  A department of a provider may not 
itself be qualified to participate in Medicare as a provider under 489.2 of this chapter, 
and the Medicare conditions of participation do not apply to a department as an 
independent entity. For purposes of this part, the term department of a provider does 
not include an RHC or, except as specified in paragraph (n) of this section, an FQHC. 
 
Remote location of a hospital:  means a facility or organization that is either created 
by, or acquired by, a hospital that is the main provider for the purpose of furnishing 
inpatient hospital services under the name, ownership, and financial and administrative 
control of the main provider, in accordance with the provisions of this section.  A 
remote location of a hospital comprises both the specific physical facility that serves as 
the site of services for which separate payment could be claimed under the Medicare 
or Medicaid program, and the personnel and equipment needed to deliver the services 
at that facility.  The Medicare conditions of participation do not apply to a remote 
location of a hospital as an independent entity.  For purposes of this part, the term 
remote location of a hospital does not include a satellite facility as defined in 
412.22(h)(1) and 412.25(e)(1) of this chapter. 
 
Provider-based entity:  means a provider of health care services, or a RHC as 
defined in 405.2401(b) of this chapter, that is either created or acquired by the main 
provider for the purpose of furnishing health care services of a different type from 
those of the main provider under which the ownership and administrative and financial 
control of the main provider, in accordance with the provisions of this section.  A 
provider-based entity comprises both the specific physical facility that serves as the 
site of services of a type for which payment could be claimed under the Medicare or 
Medicaid program, and the personnel and equipment needed to deliver the services at 
the facility.  A provider-based entity may, by itself, be qualified to participate as a 
provider under 489.2, and the Medicare conditions of participation do apply to a 
provider-based entity as an independent entity. 
 
Provider-based status:  means the relationship between a main provider and a 
provider-based entity or a department of a provider, remote location of a hospital, or a 
satellite facility, that complies with the provisions of this section. 
  The CAH off-campus location regulations at 485.610(e)(2) apply to off-campus distinct 
part units, as defined at 485.647, to departments that are off-campus, to remote locations 
of CAHs, as defined at 413.65(a)(2), and, on or after October 1, 2010, to off-campus 
facilities that furnish only clinical diagnostic laboratory tests operating as parts of CAHs.  
The requirements apply, regardless of whether the CAH is a grandfathered necessary 
provider CAH or not.  However, the regulations also specifically state that they do not 
apply to RHCs that are provider-based to a CAH. 
 
These regulations also do not apply to the following types of facilities/services owned and 
operated by a CAH, because such facilities or services generally are not eligible for 
provider-based status, in accordance with 413.65(a)(1)(ii): 
 
  Ambulatory surgical centers (ASCs); 
 
  Comprehensive outpatient rehabilitation facilities (CORFs); 
 
  Home Health Agencies (HHAs); 
 
  Skilled nursing facilities (SNFs); 
 
  Hospices;  
 
  Independent diagnostic testing facilities furnishing only services paid under a fee 
schedule, such as facilities that furnish only screening mammography services, 
facilities that furnish only clinical diagnostic laboratory tests, other than those 
operating as parts of a CAH, or facilities that furnish only some combination of 
these services. 
 
  ESRD facilities; 
 
  Departments of providers that perform functions necessary for the successful 
operation of the CAH, but for which separate CAH payment may not be claimed 
under Medicare or Medicaid, e.g., laundry, or medical records department; and  
 
  Ambulances. 
 
In the case of Federally Qualified Health Centers (FQHCs), although CMS rules permit 
them to be provider-based departments of a hospital or CAH, it is unlikely that there are 
new FQHCs that meet the provider-based criteria, since Health Resources and Services 
Administration (HRSA) requirements for separate FQHC governance make it unlikely an 
FQHC could meet provider-based governance requirements.  However, there are 
grandfathered FQHCs that were in operation prior to April 7, 2000, which are permitted to 
retain their provider-based status. 
 
Provider-based determinations are site-specific and based on the facilitys location with 
respect to the main campus when the attestation is made to the RO.  If a CAH relocates an 
off-campus facility, including off-campus facilities that were in existence or under  development prior to January 1, 2008, and are currently grandfathered, the off-campus 
facility must comply with the requirements at 485.610(e)(2) and the provider-based rules 
at 413.65.  The CAH will resubmit an attestation to the RO for the new location to 
determine if it meets all the requirements at the new location. 
 
In addition, if the main campus of the CAH relocates, it may wish to obtain a provider-
based determination for all of its off-campus locations.  However, this is a voluntary 
decision on the part of the CAH.  There is no need for a new determination of compliance 
with the CAH location requirements at 485.610(e)(2) when there is no change of location 
of the off-campus facilities. If the CAH seeks a provider-based determination, the RO 
conducts the review in the same manner as described below. 
 
Process Requirements 
 
Under the general provider-based rules at 413.65, hospitals and CAHs are not required to 
seek an advance determination from CMS that their provider-based locations meet the 
provider-based requirements, but many choose to do so rather than risk the consequences 
of having erroneously claimed provider-based status for a facility.  However, 
485.610(e)(2) provides that a CAH can continue to meet the location requirement at 
485.610(c) only if the off-campus provider-based location or off-campus distinct part 
unit is located more than a 35 mile drive (or 15 mile drive in the case of mountainous 
terrain or in areas where only secondary roads are available) from a hospital or another 
CAH.  Therefore, a CAH should seek an advance determination of compliance with 
the CAH location requirements for any off-campus provider-based facility 
established on or after January 1, 2008. 
 
If a CAH submits a provider-enrollment application (Form CMS-855) to its affiliated 
Medicare Administrative Contractor (MAC) noting that it is adding a provider-based 
location, the CAH should also submit documentation noting how it continues to comply 
with the CAH distance requirements at 485.610(e)(2) to ensure that the CAH will retain 
its status as a CAH. 
 
The MAC reviews the CAHs Form CMS-855 for addition of a provider-based location 
and, once completed, forwards the form and any submitted documentation to their CMS 
affiliated Regional Office (RO) Division of Survey and Certification (DSC) for review of 
compliance with 485.610(e)(2).  If the CAH does not submit documentation noting how 
it continues to comply with the CAH distance requirements in the provider-enrollment 
application (Form CMS-855), the CMS RO DSC requests that information from the CAH 
during their distance review. 
 
The RO DSC reviews the Form CMS-855 and any corresponding documentation from the 
CAH as well as any information received from the SA for evidence that the CAHs off-
campus provider-based location is more than a 35 mile drive (or 15 miles in the case 
of mountainous terrain or an area with only secondary roads) from another hospital 
or CAH.   
  If the RO DSC verifies that the CAH will continue to meet the 485.610(e)(2) distance 
requirements with the added provider-based location, the RO DSC issues a tie-in notice 
and notifies the MAC, the CMS RO Division of Financial Management and Fee for 
Service Operations (DFMFFSO), and the SA of the tie-in.    
 
However, if the RO DSC review verifies that the CAHs provider-based location does not 
meet the CAH distance requirements at 485.610(e)(2), the RO DSC notifies the CMS 
Central Office (CO), the MAC, the RO DFMFFSO, and the SA.  Once notified of the RO 
DSC review: 
 
  The MAC does not take further action on the submitted CAH Form CMS-855 to add 
the provider-based location (under Chapter 15 of the Medicare Program Integrity 
Manual) until the MAC is notified of the CAHs decision as outlined below. 
 
  The RO DSC informs the CAH that its provider-based location causes the CAH to no 
longer meet the 485.610(e)(2) distance requirement and offers the CAH the following 
options (A, B, or C): 
 
A.  Termination of participation:  By adding the provider-based location, the CAH 
would be placed on a 90 day termination track (as outlined in Section 3012 of the 
SOM) or the CAH can voluntarily terminate its participation from the program all 
together. 
 
B.  Continued CAH certification:  The CAH may retain its CAH status by 
terminating the off-campus provider-based location arrangement that led to the 
non-compliance with the 485.610(e)(2) distance requirements within the 90 day 
termination period or by physically moving the provider-based location so that the 
distance requirements are met. 
 
C.  Conversion:  The CAH may continue to participate in Medicare by converting to a 
hospital.  If the CAH chooses to convert to a hospital, the CAH would need to 
submit to the MAC another Form CMS-855 to terminate their CAH enrollment 
along with a separate Form CMS-855 to enroll as a hospital.  The effective date of 
the CAHs hospital certification would coincide with the effective date of 
termination of CAH status.  See Section 2005 of the SOM for the Medicare 
enrollment process. 
 
Once the RO DSC notifies the MAC of its review that the CAH is in compliance with 
485.610(e)(2) distance requirements or, if not in compliance, of the CAHs choice of 
option A, B, or C (as described above), the MAC then proceeds with sending the Form 
CMS-855 and its recommendation for approval on the provider-based location to its 
affiliated RO DFMFFSO for a determination under 413.65. 
 
  The RO DFMFFSO reviews the Form CMS-855 and confers with CMS CO and RO 
DSC on specific issues as needed. 
    The RO DFMFFSO sends the CAH/Hospital (Form CMS-855 applicant) a notice letter 
with the determination on its request for provider-based location designation, with 
copies sent to the MAC, RO DSC, and the SA). 
 
The CAH must comply with all applicable requirements at 485.610(e)(2) for the distance 
requirements and 413.65 for the provider-based rules.   
 
During the review process, CMS RO DFMFFSO also considers additional issues such as 
the following (this list is provided for informational purposes only; it is not all-inclusive): 
 
  The off-site facility must operate under the same license of the main provider, 
except in areas where the State requires a separate license for facilities that 
Medicare would treat as the department of the provider or in areas where State law 
does not address licensure. 
 
  The clinical services of the off-site facility and the CAH main provider are fully 
integrated as evidenced by: 
 
  Professional staff have clinical privileges at the main provider; 
 
  The main provider maintains the same monitoring and oversight of the off-
campus facility as it does for any other department of the provider; 
 
  The medical director or other similar official of the off-campus facility 
maintains a reporting relationship with the chief medical officer or other 
similar official of the main provider and is under the same type of 
supervision and accountability, and reporting as any other director, medical 
or otherwise of the main provider; 
 
  Medical staff committees or other professional committees at the main 
provider are responsible for medical activities in the off-campus facility 
and the main provider.  This includes quality assurance, utilization review, 
and the coordination and integration of services, to the extent practical, 
between the off-campus facility and the main provider; 
 
  Medical records for patients treated in the off-campus facility are integrated 
into a unified retrieval system (or cross-referenced) of the main provider; 
and 
 
  Inpatient and outpatient services of the off-campus facility and the main 
provider are integrated, and patients treated at the off-campus facility who 
require further care have full access to all services of the main provider and 
are referred where appropriate to the corresponding inpatient or outpatient 
department of the main provider. 
 
  The financial operations of the off-campus facility are fully integrated within the 
financial system of the main provider;   
  The off-campus facility is held out to the public as part of the main provider.  
When patients enter the off-campus facility, they are made aware they are entering 
the main provider and will be billed accordingly; 
 
  The off-campus facility is operated under the ownership (100 percent) and control 
of the main provider; 
 
  The reporting relationship between the off-campus facility and the main provider 
must have the same frequency, intensity, and level of accountability that exists 
between the main provider and one of its existing departments; 
 
  The off-campus facility is located within a 35 mile radius of the main provider.  
This distance is measured in radial miles or a straight line measurement between 
the main provider and the provider-based department, remote location, and/or 
distinct part unit; 
 
  Off-campus outpatient departments must also comply with the following: 
 
  Physician services furnished in a department of the CAH must be billed 
with the correct site of service so that appropriate physician and 
practitioner payment amounts can be made; 
 
  CAH outpatient departments must comply with all of the terms of the 
CAHs provider agreement, including the CAH Conditions of Participation 
at 42 CFR Part 485, Subpart F; 
 
  Physicians working in departments of the main provider are obligated to 
comply with the non-discrimination provisions in 489.10(b); 
 
  CAH outpatient departments must treat all Medicare patients, for billing 
purposes, as CAH outpatients; and 
 
  When Medicare beneficiaries are treated in CAH outpatient departments 
that are located off-campus, the treatment is not required to be provided by 
the anti-dumping rules in 489.2, unless the off-campus facility meets the 
EMTALA definition of a dedicated emergency department found at 42 
CFR 489.24(b). 
 
Termination for Noncompliance 
 
A CAH that is found to be out of compliance with the off-campus location requirements at 
485.610(e)(2) is subject to termination of its Medicare provider agreement.  In such 
cases, the CAH is placed on a 90-day termination track, as outlined in 3012.  If the CAH 
corrects the noncompliance within this 90-day period, by terminating the off-campus 
provider-based arrangement that led to the non-compliance, then the provider agreement is 
not terminated.   
A facility facing termination of its CAH status as a result of non-compliance with 
485.610(e)(2) distance requirements could also continue to participate in Medicare by 
converting to a hospital, assuming that the facility satisfies all requirements for 
participation as a hospital in the Medicare program under the provisions at 42 CFR Part 
482.  Under the scenario of a CAH not meeting the CAH distance requirements at 
485.610(e)(2), the CAH would have the choice of  
A, B, or C  
 
A.  Termination of Participation:  By adding the provider-based location, the CAH 
would be placed on a 90 day termination track (as outlined in Section 3012 of the 
SOM) or the CAH can voluntarily terminate its participation from the program all 
together. 
 
B.  Continued CAH certification:  The CAH may retain its CAH status by 
terminating the off-campus provider-based location arrangement that led to the 
non-compliance with the 485.610(e)(2) distance requirements within the 90 day 
termination period or by physically move the provider-based location so that the 
distance requirements are met. 
 
C.  Conversion:  The CAH may continue to participate in Medicare by converting to a 
hospital.  If the CAH chooses to convert to a hospital, the CAH would need to 
submit to the MAC another Form CMS-855 to terminate their CAH enrollment 
along with a separate Form CMS-855 to enroll as a hospital.  If the CAH fails to 
comply with the CAH CoPs, and fails to convert and comply to the hospital CoPs, 
the provider agreement will be terminated.  If the CAH applies to convert back to a 
hospital and meets the hospital CoPs, the effective date of the CAHs hospital 
certification would coincide with the effective date of termination of CAH status.  
A new CCN number would be assigned accordingly.  See Section 2005 of the 
SOM for the Medicare enrollment process. 
 
Beginning October 1, 2010, off-campus CAH-owned clinical diagnostic laboratory 
facilities that do not satisfy the requirements to be provider-based to a CAH, including 
applicable distance requirements, may continue to participate separately in Medicare as a 
clinical diagnostic laboratory, but will no longer be considered to be part of the certified 
CAH. 
 
2257 - CAH Anti-Dumping Requirements 
 
(Rev. 1, 05-21-04) 
 
Medicare participating hospitals must meet the requirements in 1867 of the Act, 
Examination and Treatment for Emergency Medical Conditions and Women in Labor, 
and the applicable provisions of 1866 of the Act.  The regulatory requirements are found 
in 42 CFR 489.24 and 489.20(l),(m),(q) and (r).  For purposes of the anti-dumping 
requirements the term hospital includes CAHS.  The provisions of 1867 apply to all 
individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital or a  CAH for emergency care.  The SA will investigate any alleged violation by a CAH 
according to the procedures found in the SOM.  
 
2258 - Advance Directive Requirements for CAHS 
 
(Rev. 1, 05-21-04) 
 
The requirements at 42 CFR 489.100, 489.102, and 489.104, apply advance directive 
requirements to CAH inpatients, including inpatients receiving SNF level of care in 
swing-beds.  When the SA is conducting a CAH survey, apply the advance directive 
requirement to all CAH inpatients.   
 
2259 - Procedures for Processing CAH Swing-Bed Applications 
 
(Rev. 1, 05-21-04) 
 
A facility that has been designated as a CAH by the State and certified as a CAH by CMS 
may apply at any time to participate in the swing-bed program. Application is made using 
a letter on the providers letterhead requesting participating for swing-beds.  Only CMS 
can approve an application to participate in the Medicare swing-bed program. 
 
2259A - Definition, Authority and Requirements for CAH Providers of 
Extended Care Services (Swing-Beds) 
 
(Rev. 1, 05-21-04) 
 
Swing-bed is a reimbursement term that means the care and reimbursement for the care 
of a patient in a small rural hospital or CAH swings from acute care to post hospital 
skilled nursing care (SNF).  A swing-bed hospital means a hospital or CAH participating  
in Medicare that has an approval from CMS to provide post hospital SNF care and meets 
the requirements specified in 482.66 for a hospital or 485.645 for a CAH. 
 
Certification to provide swing-beds is an approval separate from the certification to 
operate as a hospital or CAH.  When a survey of swing-beds is completed, any 
deficiencies and Plans of Correction (PoC) must be documented on a separate Form CMS-
2567.  If the swing-beds are voluntary terminated or terminated by CMS, that action does 
not affect the continuing operation of the provider as a hospital or CAH.  It terminates the 
approval to operate and receive reimbursement for the swing-beds. 
 
The swing-beds in a hospital or CAH do not have to be separated from the acute patients 
although the facility may choose to do so. The patients do not have to move to a different 
location in the facility when changing from acute care status to swing-bed status unless the 
facility requires it. 
 
There is no length of stay restriction for a swing-bed patient whether they are in a hospital 
or a CAH.  There is no required discharge to a nursing home and no transfer agreement. 
Patients may be discharged to a nursing home as part of discharge planning, but it is not  required.  
 
A medical order in the chart by the physician is required to change status from acute care 
to swing-bed because the patient is being discharge from acute care status and admitted to 
swing-bed status.  This is necessary for reimbursement purposes because the billing and 
reimbursement change or swing.  Accordingly, the facility is given a sub-provider 
number for billing swing-bed services. 
 
For Medicare patients, a 3-day qualifying stay in any hospital or CAH is required to prior 
to admission to a swing-bed and the admission must be for treatment of the same 
condition.  This 3-day qualifying stay only applies to a Medicare patient. 
 
NOTE:  The 30-day patient transfer notice requirement at 42 CFR Part 483.12(a)(5) does 
not apply to swing-bed CAHS. 
 
2259B - Request from a Medicare Participating CAH to add Swing-bed 
Approval 
 
(Rev. 1, 05-21-04) 
 
The request can be initiated on the providers letterhead stationery and sent to the SA.  
Acknowledgement and request for further information can be sent from the SA to the 
provider in a letter. 
 
2259C - Pre-Survey Activity 
 
(Rev. 1, 05-21-04) 
 
Prior to scheduling a survey, the SA reviews the provider file as well as any other 
information maintained on the CAH. If  the CAH requirements are met and the CAH has 
begun to provide swing-bed services, the SA schedules a survey.  No CAH may receive 
initial swing-bed approval without an onsite survey of the actual provision of such 
services.  The SA may send a letter to the provider notifying them of a future survey.  
Prior to survey the SA verifies that the hospital has a valid Medicare provider agreement. 
 
2259D - Certificate Of Need (CON) Approval 
 
(Rev. 1, 05-21-04) 
 
States that have a  CON requirement for the initiation or expansion of long-term care 
services may require a CON for a limited number of beds for LTC use.  There is no 
federal requirement for a CON but CMS will not intervene if there is a state requirement. 
 
2260 - Survey Procedures for Swing-Bed Approval 
 
(Rev. 1, 05-21-04) 
  The SA surveys any CAH that meets CAH requirements and that has begun to provide 
post-hospital SNF and NF care services.  The SA may choose to use the optional Swing-
Bed Survey Report that can be found with  Appendix W to record survey findings.  
 
The survey for swing-bed approval may be conducted at the same time as a survey of the 
CAH CoP at 42 CFR Part 485, although the findings must be documented on a separate 
Form CMS-2567. 
 
2261 - Post-Survey Procedures for Swing-Bed CAHS 
 
(Rev. 1, 05-21-04) 
 
To receive swing-bed approval, a CAH must be found in compliance with the provisions 
of 42 CFR Part 485.645 and the specific skilled nursing requirements in 42 CFR 483 
that apply to swing-bed CAHS, see Appendix W.  If a plan of correction is required 
following the survey, send a copy of Exhibit 151, Request for a Plan of Correction 
Following an Initial CAH Survey, to the provider. 
 
Effective dates for all swing-bed approvals are based on the provisions at 42 CFR 489.13 
that state the agreements will be effective on the date the onsite survey is completed if all 
Federal requirements are met on the date of the survey.  If the provider fails to meet any of 
the requirements, the approval will be effective on the earlier of the following dates: 
 
  The date on which the prospective CAH meets all requirements; or 
 
  The date the prospective CAH submits a correction plan acceptable to CMS. 
 
2262 - RO Approval Procedures for Swing-Bed Approval 
 
(Rev. 1, 05-21-04) 
 
The RO prepares a formal determination and notifies the CAH of its approval or denial.  
For approvals, see Exhibit 150B,Approval Notification for Swing-beds in a Hospital, or 
denials, see Exhibit 149, CAH Denial for Medicare Participation.  
 
If the provider is found to be in non-compliance after they have started to provide swing-
bed services, a termination of the approval can be accomplished through a termination  
letter, see Exhibit 152, CAH Termination Letter.  Failure to satisfy requirements for 
swing-bed approval does not affect Medicare approval as a provider of hospital services, 
but it does withdraw the approval to provide SNF level services at the CAH. 
 
    End Stage Renal Disease (ESRD) Facilities 
 
2270 - Medicare and ESRD 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The Social Security Act (the Act) designates those providers and suppliers that are subject 
to Federal health care quality standards.  Dialysis facilities are so designated under 
1881(b)(1) of the Act.  
NOTE: The terms ESRD facility and dialysis facility are used interchangeably in this 
document.  
ESRD is that stage of renal impairment that appears irreversible and permanent, and 
requires a regular course of dialysis or kidney transplant to maintain life. Section 1802 of 
the Act provides that any individual entitled to Medicare may obtain health services from 
any institution, agency, or person qualified to participate in Medicare if that institution, 
agency, or person undertakes to provide that individual such services.  
The ESRD Conditions for Coverage (CfCs) set baseline standards for ESRD facilities to 
meet when furnishing dialysis services which apply to all patients receiving care from the 
Medicare-approved facility, not just those who are Medicare beneficiaries.  All dialysis 
patients must receive care that meets or exceeds the CfCs. 
 
2270A  ESRD Conditions for Coverage 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Social Security Act 1881(b)(1) 
Section 1881(b)(1) of the Act requires dialysis facilities to comply with the Conditions for 
Coverage (CfCs) for End-Stage Renal Disease (ESRD) Facilities in 42 CFR Part 494.  
These regulations specify the conditions with which facilities must comply to achieve and 
maintain approval for Medicare reimbursement. 
 
Conditions for Coverage  
The current CfCs for ESRD facilities were comprehensively updated through a final rule 
that was published on April 15, 2008, with an effective date of October 14, 2008 for most 
of the requirements.  The requirement for an isolation room or area for hepatitis B virus 
positive (HBV+) patients at 494.30 became effective February 9, 2009.  Some provisions 
addressing Life Safety Code (LSC) for ESRD facilities at 494.60 were updated though a 
final rule (77 FR 29002) that was published May 12, 2012, which became effective on 
July 16, 2012. The requirement for emergency preparedness at 494.62 became effective 
November 15, 2016 with an implementation of November 15, 2017. 
 
2270B - ESRD Survey and Certification Communication, Information, 
Tools 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
In order to foster communication among States Survey Agencies, CMS Regional Offices, 
and the ESRD community, the following website may be accessed for ESRD information 
and updates:    CMS Dialysis Survey and Certification web site  
The website contains: 
  Hyperlinks to the 2008 Final Rule, Conditions for Coverage for End-Stage Renal 
Disease Facilities and the Interpretive Guidance (IGs);  
  Frequently Asked Questions (FAQs) submitted by ESRD surveyors and the public 
since the implementation of the 2008 CfCs.  The FAQs are organized by respective 
Conditions and V-tags in the IGs and are updated periodically with new questions 
and answers that are noted in red for easy reference; 
  Survey tools and training materials including, but not limited to, the ESRD Core 
Survey Field Manual, Outline of the ESRD Core Survey Process, ESRD Core 
Survey Process Triggers, the Measures Assessment Tool (MAT), critical water and 
dialysate requirements, a list of V-tags and identifiers, information on infection 
control and requirements for isolation rooms/areas, ESRD personnel requirements 
including information on organizations that certify dialysis patient care 
technicians, components of immediate jeopardy, and a list of helpful web sites for 
ESRD surveyors; 
  ESRD program-related survey and certification memoranda; and 
  Hyperlinks to ESRD-related web sites within and external to CMS. 
 
2270C  Definitions 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Dialysis 
Dialysis is a process by which waste products are removed from the body by diffusion 
from one fluid compartment to another across a semi-permeable membrane.  There are 
two types of renal dialysis procedures in common clinical usage: hemodialysis and 
peritoneal dialysis.  Both hemodialysis and peritoneal dialysis are modalities of treatment 
for ESRD under Medicare and can be performed in a dialysis facility or in the patients 
residence.   
Hemodialysis 
In hemodialysis (HD), blood from the patients body is passed through blood lines and a 
hemodialyzer (artificial kidney) with the use of a hemodialysis machine.  Hemodialysis 
uses osmosis and diffusion to remove waste products and excess fluids.  Access to the 
patients blood circulation is required.  Through exposure to a prescribed solution called 
dialysate, the patients blood is cleansed and extra fluid is removed.  The cleansed blood is 
returned to the patients bloodstream.  Hemodialysis is most commonly conducted 3 times 
a week with each session lasting 3 to 5 hours.  It can also be conducted in 4 to 6 shorter 
sessions per week or in 3 to 6 overnight sessions lasting 6 to 8 hours each.  Hemodialysis 
can be performed in a dialysis facility or at the patients home. 
 
Peritoneal Dialysis 
 
Peritoneal dialysis (PD) uses the patients peritoneal membrane as the filter, and direct 
access to the patients blood system is not required.  A permanent tube (catheter) is 
surgically placed through the skin into the peritoneal space to allow introduction of a 
prescribed solution (dialysate).  Waste products pass from the patients blood through the 
peritoneal membrane into this fluid, which is drained and exchanged for clean solution  periodically.  Peritoneal dialysis can be done manually four to five times daily at spaced 
intervals or may be done using a machine (called a cycler) 7 to10 hours daily, generally 
overnight.  The length of time, number of exchanges, and content of the dialysate is based 
on the physicians prescription.  PD is usually performed in the patients home but may be 
performed in-center for ESRD facilities approved for in-center PD.   
 
Intermittent Peritoneal Dialysis (IPD) 
Waste products pass from the patients body through the peritoneal membrane into the 
peritoneal cavity where the dialysate is introduced and removed periodically by machine. 
Peritoneal dialysis generally is required for approximately 30 hours a week, either as three 
10-hour sessions or less frequent, but longer, sessions. 
 
Continuous Ambulatory Peritoneal Dialysis Coverage (CAPD) 
In CAPD, the patients peritoneal membrane is used as a dialyzer. CAPD does not require 
machinery or water supplies since the dialysate comes prepackaged in plastic bags ready 
for use.  CAPD requires implantation of an indwelling catheter to provide access to the 
peritoneum.  The patient connects the 2-liter plastic bag of the dialysate to the catheter, 
and the fluid infuses into the peritoneal cavity.  Four to six hours later, the patient drains 
the fluid into a new drain bag and refills the peritoneal cavity with fresh dialysate.  The 
procedure is accomplished three to five times daily, with the first exchange made upon 
arising and the last at bedtime.  The procedure not only frees the patient from a machine 
but also allows scheduling flexibility without many of the restrictions associated with 
other types of dialysis. 
 
Continuous Cycling Peritoneal Dialysis (CCPD) 
CCPD uses an automated peritoneal dialysis machine to infuse a prescribed amount of 
dialysate into the abdomen and drain it, depending on the prescription.  The process is 
repeated for 8 to 10 hours a day, usually at night while the patient sleeps.  The last 
exchange stays in the abdomen during the day.  Thus the patient cycles at night, but 
continuously dialyzes during the day. 
 
2271 - General Requirements for In-center and Home Dialysis Program  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
In-Center Dialysis: 
 
Approval to provide in-center dialysis includes approval for a specific number of dialysis 
stations for that modality.  A dialysis station is an individual patient treatment area that 
provides sufficient space to accommodate the dialysis equipment and supplies needed for 
routine care and any emergency care indicated.  There must be sufficient separation from 
other dialysis stations to afford protection from cross-contamination with blood-borne 
pathogens.  A hemodialysis station is equipped with an adjustable chair or bed, a 
hemodialysis machine, and, depending on the hemodialysis machine being used, access to 
a purified water source and dialysate concentrates.   
 
Federal regulations do not have space/dimension requirements for in-center dialysis 
stations or home dialysis training and support areas.  Some State regulations may identify  space/dimension and other requirements for each in-center dialysis stations and the home 
dialysis training and support room/area. 
Home Training and Support Program: 
Approval to provide home training and support services requires the dialysis facility to 
provide both home training to the patient and/or their care partner in the modality and 
ongoing support and monitoring of the patient/care partner, as outlined in 42 CFR 
494.100.  An approved home training and support program must include both training 
and support services. A dialysis facility that is approved to provide services to home 
patients must ensure through its interdisciplinary team that home dialysis services are at 
least equivalent to those provided to in-facility patients and meet all applicable ESRD 
CfCs.  
 
There are no requirements for a specification of the number of training stations.  The 
expectation for these services is that there will be sufficient space to provide an 
appropriate learning environment for each patient and care partner, if applicable.  The in-
facility home dialysis training and support space must be large enough to accommodate 
the dialysis equipment, routine and emergency care, to afford patient privacy, and to 
prevent cross-contamination with pathogens. 
In accordance with 494.100(c)(1)(vii), facilities which provide only home dialysis 
training and support must have a plan/arrangement in place to provide emergency back-up 
dialysis services when there is an interruption, or anticipated interruption, in a patients 
routine home dialysis treatment. Situations that may require back-up dialysis services 
include, but are not limited to, non-functional equipment, power or water outages, 
availability of a designated care partner and/or a patients anticipated travel away from 
their home.   
The home dialysis support services may be provided directly by the ESRD facility or by 
arrangement with another ESRD facility.  If the support services are provided by another 
ESRD facility, such arrangements should be made at a location as convenient to the 
patients home as possible, regardless of facility ownership.   
2271A - Dialysis in Nursing Homes 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Terms Used in This Guidance 
The term nursing home in this guidance refers to a Skilled Nursing Facility (SNF) or a 
Nursing Facility (NF). The term ESRD facility refers to the certified end-stage renal 
disease (ESRD) facility that retains overall responsibility for all the dialysis care and 
services of the patient. 
Overview: Dialysis for Nursing Home Residents  
Medicare reimbursement for dialysis services is available to certified ESRD facilities. All 
dialysis patients must be under the care of a certified ESRD facility to have their 
outpatient dialysis care and treatments reimbursed by Medicare. 
Nursing homes are not required to accommodate dialysis services on-site. Some State 
regulations may not allow dialysis services to be provided in a nursing home setting, or  may have additional requirements regarding the qualifications of personnel who provide 
dialysis treatments in a nursing home. 
Residents of a nursing home may receive chronic dialysis treatments through two options: 
1.  In-Center Dialysis:  
  Transporting the resident to and from a separately certified ESRD facility  that 
is located off-site of the nursing home for dialysis treatments; or 
  Transporting the resident to and from a separately certified ESRD facility 
providing in-center dialysis located within the nursing home or proximate to 
the nursing home building. 
 
2.  Home Dialysis in a Nursing Home:  
Residents may receive dialysis treatments in the nursing home. These dialysis 
treatments are administered and supervised by personnel who meet the criteria for 
training, and competency verification in 42 CFR 494.100(a) and (b) as also stated 
in this guidance, and are provided through a written agreement between the 
nursing home and the ESRD facility. 
Mitigating risks for residents receiving dialysis treatments in a nursing home include: 1) 
ensuring only qualified personnel administer, monitor, and supervise the dialysis 
treatments; 2) monitoring the dialysis patients status before, during, and after the 
treatments; and 3) ensuring a safe and sanitary environment for the treatments. 
The goal of this guidance is to ensure that an ESRD facility, providing home dialysis 
services to a nursing home resident under a written agreement with the residents nursing 
home, maintains direct responsibility for the dialysis related care and services provided to 
the nursing home resident(s) consistent with the ESRD Conditions for Coverage (CfC) 
requirements as well as the terms of an applicable agreement with the nursing home. 
ESRD Notification to the State Survey Agency of a New or Additional Contract with 
a Nursing Home to Provide Dialysis Services On-Site 
No additional approval is required from CMS for an ESRD facility to enter into an 
agreement with a nursing home to provide dialysis services to nursing home residents.  
However, the ESRD facility must notify its State Survey Agency (SA) of any such 
agreement(s).  This notification is accomplished through submitting a completed Form 
CMS-3427 End Stage Renal Disease Application and Survey and Certification Report.  
Only the following applicable fields of the Form CMS-3427 must be completed for this 
notification: 
  Field: (1)    #6 Other 
  Field: (2)    Name of Dialysis Facility 
  Field: (3)    CCN 
  Field: (4)    Street Address of Dialysis Facility  
  Field: (6)    City 
  Field: (7)    County 
  Field: (9)    State  
  Field: (10) Zip Code 
  Field: (12)  Telephone Number 
  Field: (22)  Dialysis in LTC Facility Field: 
  Field: (26)  How is isolation provided in the nursing home? 
 
Written Agreement between the ESRD Facility and the Long Term Care Facility    
The ESRD facility is expected to enter into a written agreement with any individual 
nursing home for which they will provide dialysis services.  The agreement delineates the 
responsibilities of the ESRD facility and the nursing home regarding the care of the 
resident before, during, and after dialysis treatments. 
 
The ESRD facility is ultimately responsible for the safe delivery of dialysis to the nursing 
home resident which would include review of the qualifications, training, competency 
verification, and monitoring of all personnel who administer dialysis treatments in the 
nursing home and who provide on-site supervision of dialysis treatments.  The ESRD 
facility is responsible for the quality and safety of the dialysis treatments and the 
management of the residents ESRD-related conditions.  The ESRD facility is also 
responsible for providing all equipment necessary for the residents dialysis treatment and 
for the maintenance of such equipment. 
The nursing home is responsible for providing a safe environment for the dialysis 
treatments, monitoring the resident before, during, and after dialysis treatments for 
complications possibly related to dialysis, and provides all non-dialysis related care.  
Nursing home staff must be prepared to appropriately address and respond to dialysis 
related complications and provide emergency interventions, as needed. See 42 CFR 
483.25(l) and SOM App. PP at tag F698. 
Both the ESRD facility and the nursing home are responsible for ensuring the 
collaboration necessary to provide dialysis care coordination to each nursing home 
resident receiving dialysis treatments. 
The written agreement must be signed by authorized representatives of the Medicare-
certified dialysis facility and the nursing home prior to the provision of dialysis care at the 
nursing home and must: 
1.  Delineate the lines of authority of each party;  
2.  Delineate the responsibilities of each party; 
3.  Describe how coordination between the parties will occur;  
4.  Describes the accountability for the dialysis services provided; 
5.  Be consistent with the written policies and procedures of the ESRD facility and the 
nursing home; 
6.  Specify the method by which the parties will ensure adherence to the terms of the 
agreement, communicate as issues arise, and take remedial action when 
appropriate; and 
7.  Be reviewed at least annually, and updated as needed. 
 
ESRD Policies and Procedures for Services to Residents Located in a Nursing Home  
At a minimum, the ESRD facility, in collaboration with the nursing home, must develop 
and implement protocols for the delivery of ESRD services that are equivalent to the 
standards of care provided to dialysis patients receiving treatments in a dialysis facility. 
The protocols must include requirements set forth at 42 CFR 494.30 and 494.80 through 
494.100. These protocols include procedures for infection control, patient assessment, 
patient plans of care, and care of the dialysis patient at home. 
Policies and procedures must be reviewed and updated as necessary to be consistent with 
the most current standards of practice. Timeframes for re-evaluation of policies and 
procedures should be determined by each ESRD facility.  Dialysis Supervision and Administration 
The ESRD facility providing services to a resident in a nursing home must ensure: 
1.  Onsite supervision of dialysis by a trained registered nurse (RN) (who has 
completed a training course approved by the ESRD facility) whenever a resident is 
receiving hemodialysis (HD) in the nursing home, and by a trained RN or licensed 
practical/vocational nurse (LPN/LVN) (who has completed a training course 
approved by the ESRD facility) when a resident is receiving peritoneal dialysis 
(PD) treatment in the nursing home;  
2.  Qualified/trained dialysis administering personnel  are present in the room and 
maintain direct visual contact with the resident receiving HD throughout the entire 
duration of the treatment (the supervising nurse may also be the dialysis 
administering personnel); and  
3.  If a situation occurs where the nursing home is unable to provide dialysis 
treatments due to reasons such as insufficient trained staff and/or supervision, the 
ESRD facility is notified and provides the dialysis treatments to avoid a delay or 
cancellation of treatment. 
 
Documentation of training and competency verifications for nursing home staff should be 
maintained by both the ESRD and nursing home facility. 
Hemodialysis Treatment Supervision: Qualifications and Training 
The ESRD facility must ensure that a trained supervising RN is constantly present on-site 
at the nursing home and immediately available to respond to concerns or emergencies that 
may occur during a residents hemodialysis treatment.  The supervising nurse must be 
present in the general area where the resident(s) are receiving dialysis and readily 
available. If the supervising nurse has other nursing duties in the nursing home, these 
other duties must not hinder or negatively affect his/her ability to respond immediately to 
the needs of the dialysis patient(s). 
Training: RNs who supervise hemodialysis treatments in the nursing home must have 
successfully completed a training program which: 
  Covers, at a minimum, the subjects listed at 494.100 (a)(3)(i)-(viii);   
  Is approved by the dialysis facility medical director and governing body; 
  Is administered under the direction of a home training nurse meeting the 
qualifications at 494.140(b)(2); and 
  Is equivalent to the ESRD facility training and competency verification for home 
dialysis patients at 494.100 (a)(3)(i)-(viii) and 494.100(b)(1). 
 
Peritoneal Dialysis Treatment Supervision: Qualifications and Training 
 
The ESRD facility must ensure that a qualified supervising RN/LPN/LVN is constantly 
present on-site at the nursing home and immediately available to respond to concerns or 
emergencies that may occur during a residents PD treatment (i.e. automated PD, 
continuous ambulatory PD).  The supervising nurse must be present in the general area 
where the resident(s) are receiving dialysis and be readily available.  If the supervising 
nurse has other nursing duties in the nursing home, these other duties must not hinder or 
negatively affect his/her ability to respond immediately to the needs of the dialysis 
patient(s). 
  Training: RNs/LPNs/LVNs who supervise PD treatments in the nursing home must 
successfully complete a training program that is: 
  Specific to PD care and covers, at a minimum, the subjects listed at 494.100 
(a)(3)(i)-(viii)   
  Approved by the dialysis facility medical director and governing body; 
  Administered under the direction of a home dialysis training nurse meeting the 
qualifications at 494.140(b)(2)  and; 
  Equivalent to the ESRD facility training and competency verification for home 
dialysis patients at 494.100 (a)(3)(i)-(viii) and 494.100 (b)(1).  
 
Hemodialysis and Peritoneal Dialysis Administration 
 
Qualifications: The personnel who initiate and discontinue dialysis treatments for HD and 
PD to nursing home residents must be a RN, LPN or LVN who meets the practice 
requirements in the State in which he or she is employed.  A trained nursing home staff 
member such as a nurse aide or trained caregiver may monitor the patient for the duration 
of the patients treatment, but initiation and discontinuation of HD and PD must only be 
performed by the supervising nurse. 
 
Training: The dialysis administering personnel, for example RN, LPN/LVN, nurse aide 
or trained caregiver, must receive adequate training and possess sufficient competency to 
ensure that the resident on dialysis receives a safe and effective treatment. The training 
must be: 
  Equivalent to the ESRD facility training and competency verification for home 
dialysis patients at 494.100 (a)(3)(i-viii) and 494.100 (b)(1). 
  Approved by the ESRD facility medical director and governing body; 
  Administered under the direction of a  home dialysis training nurse meeting the 
qualifications at 494.140(b)(2) and; 
  Specific to the dialysis modality. The training program for HD and PD must 
include at least the subject matter listed at 494.100 (a)(3)(i-viii) . 
 
Ongoing competency for dialysis administering personnel must be verified through visual 
audits by an ESRD RN who meets the qualifications of home training nurse at 
494.140(b)(2) . Frequency for competency verification is determined by the ESRD 
facility. More frequent competency checks may be warranted if problems in care are 
identified.  For example, a concern of poor clinical outcomes, such as frequent infections, 
may indicate infection control issues and may be an indicator to review dialysis 
procedures performed by the nursing home staff and possible re-training. 
In-Room Presence 
To assure resident safety, the ESRD facility and nursing home must ensure that qualified 
dialysis administering personnel remain in the room with direct visual contact of the 
resident and their vascular access throughout the hemodialysis treatment, in accordance 
with 494.60(c)(4). 
Existing Personal Caregiver 
If an existing ESRD facility home dialysis (PD or home HD) patient is admitted to a 
nursing home and that patient has a trained personal caregiver who administered the 
dialysis treatments at home, that caregiver may be approved by the ESRD facility and the  nursing home to continue to administer the patients dialysis treatments in the nursing 
home.  The collaborative decision-making process for such situations must be addressed in 
the written agreement between the ESRD facility and nursing home.  If the nursing home 
and ESRD facility determine that an existing home dialysis caregiver may continue to 
administer the dialysis in the nursing home, the ESRD facility must assure that the 
caregiver meets the training requirements at 494.100(a)(3)(i-viii), and the verification of 
demonstrated competency at 494.100(b)(1).  The ESRD facility is responsible for the 
ongoing monitoring of the competency of the personal caregiver. 
Coordination of Care 
Communication 
The ESRD facility and nursing home must establish procedures for 24/7 communication 
between the two entities.  The ESRD facility must provide to the nursing home an on-call 
schedule with the names and contact information of physicians and/or ESRD facility RNs 
to be called for emergencies.  There should be written agreement on a communication 
process to include how communication and responses will be coordinated and documented 
between the ESRD facility and nursing home staff. 
Interdisciplinary Team (IDT) Coordination between ESRD Facility and Nursing 
Home Staff 
The dialysis facility IDT team must coordinate with the nursing home staff for the 
development and implementation of an individualized care plan based on the patients 
assessment.  Both the nursing home staff and ESRD facility staff are responsible for 
monitoring and addressing any medical or non-medical needs that are identified.  Any 
identified barriers or issues that are preventing residents from meeting the established 
ESRD facility goals identified through a patient assessment and/or defined in the plan of 
care, should be promptly communicated between the ESRD facility IDT and the nursing 
home IDT.  Any barriers experienced by a dialysis patient will require re-assessment and 
an updated plan of care by both teams. 
Emergency Plans 
The dialysis facility maintains overall responsibility to prepare the nursing home to 
address all emergencies related to the dialysis needs of the resident receiving treatments in 
the nursing home.  The following emergency plans must be clear and communicated to 
nursing home staff in a manner that allows for the continuity of care and be incorporated 
into the written agreement between the two entities:  
1.  Emergency Staffing 
When the nursing home staff are functioning as the caregiver for the nursing home 
resident and providing the dialysis treatment for the resident, it is the responsibility 
of the nursing home staff to notify the ESRD facility of any delays or interruptions 
in the provision of the prescribed dialysis treatment.  The ESRD facility is 
responsible for ensuring that a backup plan is in place to ensure the resident 
receives the treatment.  
2.  Emergency Care 
Nursing Home residents receiving dialysis may have complications which require 
treatment with emergency medications or equipment. The physician treatment 
orders for the ESRD patient should include what emergency medications are to be 
kept on hand.  
3.  Equipment Failure 
The ESRD facility must provide nursing home staff with:    Adequate and appropriate education for possible equipment failures and risk(s) 
associated with equipment failures;  
  Troubleshooting techniques; and  
  Contact information for assistance in resolving issues with equipment failure. 
 
Any equipment that is non-functional must be replaced or restored by the ESRD 
facility to avoid interruption of a patients dialysis treatment. 
4.  Emergency Supplies 
Nursing homes should maintain all necessary medication and supply inventories to 
prevent any delays or interruptions to a residents prescribed dialysis treatment.  
The ESRD facility and the nursing home should ensure a reserve of supplies to be 
available in emergency circumstances.  The emergency supply reserve is in excess 
of the routine supply inventory and generally includes at least five (5) days of 
emergency supplies for each resident.  
To assist with the inventory, the ESRD facility should provide nursing homes with 
medications, equipment, and dialysis related supplies through routine deliveries.  
Plans must be in place for the safe delivery of additional supplies in the event of an 
emergency. 
 
2271B - Dialysis in Hospitals 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
A department/unit of a hospital (other than a psychiatric hospital) may, as permitted under 
State law, provide either inpatient or outpatient dialysis services.  
In certain situations dialysis services may be provided in a hospital department/unit for 
non-ESRD patients requiring temporary dialysis or for ESRD patients who are admitted to 
the hospital for other diagnoses or injuries.  These dialysis services are referred to as 
acute dialysis. A department /unit of a hospital that provides acute dialysis services must 
provide those services in compliance with the hospital Conditions of Participation (CoP) 
and are not subject to the ESRD CfCs. 
Hospitals that provide outpatient dialysis services must be certified as a hospital-based 
ESRD facility. 
 
2272 - ESRD Facility Classification  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Hospital-Based ESRD Facility 
A hospital-based ESRD facility is a separately certified ESRD facility that is an outpatient 
department of a hospital and that meets the ESRD CfCs at 42 CFR Part 494.  A hospital-
based ESRD facility is owned and administered by a hospital or critical access hospital 
(CAH) and is physically located on the hospital campus.  If a hospital operates multiple 
separately certified hospital-based ESRD facilities, each separate ESRD facility must have 
its own CMS certification number (CCN). 
A hospital-based ESRD facility is discussed at 42 CFR 413.174(c) and meets the 
following criteria: 
  The ESRD facility and hospital have a common governing body and are subject to  the bylaws and operating policies of this body.  All management authority flows 
from this governing body which has final administrative responsibility over both 
entities.  The common governing body approves all personnel actions, appoints 
medical staff, and carries out similar management functions; 
  There is a clearly established line of authority between the ESRD facility 
administrator and the hospital chief executive officer wherein the administrator is 
under the supervision of the chief executive officer.  The ESRD facility 
administrator reports to the common governing body through the hospital's chief 
executive officer; 
  ESRD facility personnel policies and practices conform to those of the hospital; 
  Administrative functions of the ESRD facility (for example, records, billing, 
laundry, housekeeping, and purchasing) are integrated with those of the hospital; 
and 
  The ESRD facility and hospital are financially integrated, as evidenced by the cost 
report, which reflects allocation of overhead to the ESRD facility through the 
required step-down methodology. 
  Hospital-based ESRD facilities are assigned CCNs from the 2300-2499 series.  
 
Satellite Renal Dialysis Facility (Hospital-Based) 
A satellite renal dialysis facility is a hospital-owned and hospital-administered ESRD 
facility but is not located on the campus of the hospital.  A single hospital may have 
several satellite renal dialysis facilities.  Each satellite facility is separately certified and 
surveyed; must independently meet the ESRD CfCs from other facilities owned by that 
hospital; and is assigned its own CCN.   
Satellite renal dialysis facilities (Hospital-Based) are assigned CCNs in the 3500-3699 
series. 
Independent Renal Dialysis Facility 
An independent renal dialysis facility is any ESRD facility that does not meet the 
definition of a hospital-based renal dialysis facility or satellite renal dialysis facility as 
described in the paragraphs above.  An independent renal dialysis facility may be 
physically located on a hospital campus, but is not owned and/or administered by the 
hospital.   
Independent renal dialysis facilities are assigned CCNs in the 2500-2899 series. 
Special Purpose Renal Dialysis Facility (SPRDF) (494.120) 
This type of renal disease facility is temporarily certified to furnish dialysis at special 
locations on a short-term basis (i.e. up to 8 months in any 12 month period) to a group of 
dialysis patients who would otherwise be unable to obtain treatment in the geographical 
area. 
The RO must clearly specify the limited nature of the SPRDF certification, the time period 
covered by the certification, and the automatic termination of payment on the last day of 
the certification period in its notifications.  
The special locations for SPRDF fall into two categories: 
Vacation Camps 
Vacation camps serve dialysis patients temporarily residing there.  A vacation 
camp SPRDF would allow campers to receive hemodialysis at the camp site, 
avoiding interruption of the camping experience.  Vacation camps may be  approved for the duration of the camp, but up to a maximum of 8 months in any 
12-month period.  
Emergency Circumstance SPRDFs 
These locations are set up to provide dialysis services to those ESRD patients who 
would otherwise be unable to obtain such services in their geographical area as a 
result of a natural or man-made disaster or a need for a greater capacity to dialyze 
patients who may have been evacuated from another location.   
The RO may extend the time period in emergency SPRDF approvals, where necessary, 
beyond the standard eight-month period based upon the termination of the emergency 
condition. 
In emergency situations, the RO should coordinate with the applicable State Health 
Department to assist the ESRD Network to relocate all patients to permanent facilities 
prior to the scheduled closing date of the emergency circumstance SPRDF.  
Special purpose renal dialysis facilities are assigned CCNs in the 3700-3799 series when 
owned and administered by a hospital and in the 2900-2999 series for independent 
facilities. 
 
2273  Dialysis Modalities and Dialysis Related Services 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Dialysis is a treatment option for end stage renal disease.  Under the Medicare program, 
ESRD facilities may apply for and be approved to provide a variety of specific dialysis 
modalities and dialysis-related services.  The dialysis modalities and dialysis-related 
services are listed below.   
Dialysis Modalities 
In-center Hemodialysis: 
Under this modality, in-center hemodialysis patients receive their treatments at the ESRD 
facility, usually 2-5 times per week for varying lengths of time, generally from 3-5 hours 
as prescribed by their physician. 
In-center Nocturnal Hemodialysis 
This modality is a type of in-center hemodialysis where patients receive longer 
treatments overnight.  In-center nocturnal hemodialysis stations usually include a 
reclining chair or bed to accommodate patient comfort. 
In-center Hemodialysis- Self-dialysis 
Self-dialysis is defined in the ESRD CfCs at 42 CFR 494.10 as dialysis performed with 
little or no professional assistance by an ESRD patient or caregiver who has completed an 
appropriate course of training as specified in  494.100(a) of this part.  Self-dialysis 
refers to an individual patient's preference for performing self-care in the outpatient 
dialysis facility setting.  In contrast to home dialysis which is also defined at 494.10, 
CMS considers the self-dialysis patient as an in-center dialysis patient (or their personal 
care partner) who wishes to self-administer most or all of their dialysis treatment without 
professional help in one of the approved in-center dialysis stations of the certified ESRD 
facility rather than in their home. There is no separate approval for facilities that offer 
self-dialysis so long as they are approved for in-center dialysis.  
The ESRD CfCs include requirements related to the training of self-dialysis patients 
and/or care partners.  The patient or care partner must successfully complete a course of 
training that covers at least the subject matters listed at  494.100(a)(3).  The training must  be conducted by a qualified self-care/home care dialysis training nurse (who meets the 
requirements pursuant to  494.140(b)(2)), be provided by an ESRD facility which is 
approved to provide home dialysis  services ( 494.100(a)(1)). The facility must verify the 
competency of the patient/care partner in the administration of the dialysis treatments, and 
document the verification in the patient's medical record ( 494.100(b)(1)). 
In-center dialysis patients who wish to self-administer a minor portion of their treatments, 
such as inserting their own needles, or taking their own blood pressures do not meet the 
definition of self-dialysis.  
In-center Peritoneal Dialysis (PD) 
Although PD is primarily a home dialysis therapy, there may be situations when a patient 
is receiving PD at the dialysis facility on a temporary basis while training for home PD, or 
prior to switching to hemodialysis.  In-center PD generally requires a patient to come to 
the dialysis facility for PD treatment for eight or more hours per treatment as prescribed 
by their physician. 
Home Hemodialysis Training and Support 
The patient and/or care partner is trained to perform routine hemodialysis treatments at the 
patients place of residence by a home training nurse who meets the qualifications at 42 
CFR 494.140(b)(2).  The home dialysis training and support facility staff, inclusive of the 
interdisciplinary team, provides ongoing monitoring and support services to the patient for 
their home hemodialysis treatments. 
  Staff-Assisted Dialysis in the Home  
The dialysis facility may provide qualified staff members in the patients home to 
assist them in performing their home dialysis treatments.  The dialysis staff 
member functions in the role of the patients caregiver and monitors the patient 
throughout the dialysis treatment.  The dialysis facility maintains overall 
responsibility and oversight to ensure appropriate, qualified staff are assigned and 
trained and provides supervision of staff members as indicated.  Employees 
performing staff assisted dialysis must meet the personnel qualification 
requirements at 494.140.  
In order to provide staff-assisted home dialysis, a dialysis facility must be 
approved to provide Home Training & Support services.  Staff-assisted home 
dialysis does not require additional approval. 
Home Peritoneal Dialysis (PD) Training and Support 
The patient and/or designated care partner are trained to perform peritoneal dialysis at the 
patient's place of residence by a home training nurse who meets the qualifications at 42 
CFR 494.140(b)(2).  The home dialysis training and support staff, inclusive of the 
interdisciplinary team, provides ongoing monitoring and support services to the patient for 
their PD at home. Home PD may include Intermittent Peritoneal Dialysis (IPD), 
Continuous Ambulatory Peritoneal Dialysis (CAPD), or Continuous Cycling Peritoneal 
Dialysis (CCPD).  A dialysis facility must have an approved Home Training & Support 
program to offer IPD, CAPD, or CCPD.  IPD, CAPD and CCPD do not require additional 
approval. 
Urgent Start Peritoneal Dialysis (PD) in the ESRD Facility 
Urgent start peritoneal dialysis is the initiation of peritoneal dialysis as early as two 
weeks following catheter placement and is an option to avoid central line insertion 
for patients interested in home dialysis but requiring initiation of dialysis.  Urgent 
start PD allows the facility to support the patients dialysis related needs until the  patients catheter is healed and training is completed.  Typically, patients will 
receive peritoneal dialysis treatments in the facility up to five days/week over eight 
hours.  This process usually lasts between two to four weeks and after this period 
the patient will begin routine home PD independently in their home.   
In order to perform urgent PD, the facility must be have an approved in-center PD 
and Home Training & Support program. No separate approval is required.  
 
 
Pre-Configured Systems 
ESRD CfCs applicable to preconfigured hemodialysis systems are located at 42 CFR 
494.40 (e), Standard: In-center use of preconfigured hemodialysis system. Follow FDA 
labeling.  This requires that the systems FDA approved labeling must be adhered to for 
machine use and monitoring of the water and dialysate quality. Because this system does 
not share the same design or configuration of a traditional in-center hemodialysis water 
system, all the requirements of 494.40 Water and Dialysate Quality will not be 
applicable.  Accordingly, for purposes of surveying water and dialysate quality with 
preconfigured hemodialysis machines, the surveyor determines whether the facility 
follows the FDA and manufacturers labeling for the machine.  If that is confirmed, the 
surveyor may conclude that the preconfigured machine meets the requirements of 42 CFR 
494.40(e) and the AAMI requirements at RD52.  Maximum levels for contaminants 
including chlorine, bacteria and endotoxins in water and dialysate recommended by 
AAMI apply to both traditional in-center hemodialysis water systems and preconfigured 
systems.  
Portable Reverse Osmosis (RO) Systems 
A central water treatment and delivery system remains the traditional method for water 
purification for multiple hemodialysis machines in a dialysis facility. However, 
improvements in the manufacturing of small portable water treatment devices (i.e. 
portable reverse osmosis units) have created changes in options for water treatment in 
small chronic dialysis facilities.  The use of portable RO units in small chronic dialysis 
facilities is an alternative method of delivering AAMI quality water to the point of use 
(hemodialysis machine), if the portable RO units are appropriately constructed, monitored, 
and maintained.  The portable RO unit must produce the water quality defined in 
American National Standard Institute (ANSI)/AAMI RD52:2004, as incorporated by 
reference in 42 CFR 494.40 Condition: Water and dialysate quality.  The portable RO 
unit must be operated in accordance with manufacturers directions for use. 
Pursuant to 494.40, monitoring of each portable RO unit must include testing for total 
chlorine before each treatment, monthly microbiological monitoring of cultures and 
endotoxins, and at least annual testing of chemical quality of the product water.  
Monitoring must also include daily function monitoring and recording of the portable RO 
unit for percent rejection and the water quality produced by conductivity or total dissolved 
solids (TDS).  Surveyors should follow the guidance of the ESRD Core Survey process 
and tools, expanding their review for the above-mentioned specific requirements, when 
reviewing a facility using portable RO units. During an initial certification survey, the 
surveyor should confirm that the facilitys policies address all of these requirements. 
Dialysis-related Services 
Dialyzer Reprocessing and Reuse  A hemodialyzer (artificial kidney) is a medical device which may be manufactured for 
single use, or constructed so that it may be reprocessed and reused for hemodialysis 
following specific safety guidelines.  Reusable hemodialyzers are: 
  Assigned to an individual patient;  
  Labeled with the patients unique identifying information; 
  Rinsed/cleaned; 
  Tested for efficiency; 
  Disinfected after each hemodialysis treatment and rinsed, and 
  Tested for any residual disinfectant chemicals.  
The processes for safe and effective dialyzer reprocessing and reuse are established by the 
AAMI, which are adopted by reference into the ESRD CfCs at 42 CFR 494.50. 
Some dialysis facilities opt to transport patient dialyzers to an off-site location for 
reprocessing. This is known as a centralized reprocessing location.  Guidance for review 
of centralized dialyzer reprocessing is included in SOM section 2284, Specialized Areas 
of ESRD Oversight.  
Many dialysis facilities do not reuse hemodialyzers.  At these facilities, single-use 
dialyzers are prescribed to individual patients by type and are discarded in a biohazard 
receptacle after a single hemodialysis session. 
 
2274 - ESRD Survey and Certification Forms  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
2274A - Form CMS-855A: Medicare Enrollment Application: 
Institutional Providers 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The ESRD supplier completes the Form CMS-855A and submits it directly to the 
applicable Medicare Administrative Contractor (MAC).  The MAC will process the Form 
CMS-855A and will send a copy of any approved application to the SA and the CMS 
Regional Office.  Updates to the Form CMS 855A must be submitted to the MAC when 
there are changes to the information already submitted. 
 
2274B - Form CMS-3427: End Stage Renal Disease Application and 
Survey and Certification Report 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
In addition to the CMS-855, an ESRD facility must submit the completed Form CMS-
3427 for: 
  An initial application for participation by prospective ESRD facilities;  
  A request to expand or add in-center dialysis stations for approved modalities; 
  Change in location/relocation; 
  Change in ownership (CHOW);  
  For addition or elimination of a dialysis modality/service (s) provided, including:    In-center hemodialysis 
o
  In-center nocturnal hemodialysis 
o
  In-center peritoneal dialysis 
o
  Home hemodialysis training and support 
o
  Home peritoneal dialysis training and support 
o
  Dialysis in the Nursing Home setting 
o
  Dialyzer reprocessing and reuse  
o
 
After the completion of a survey or review, the SA must complete and upload Part II of 
the form and denote the type of survey conducted.  Instructions for completing the Form-
CMS 3427 are included on the last page of the form. 
 
2274C - Form CMS-670: Survey Team Composition and Workload 
Report  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The Form CMS-670 is completed by the survey team members for each onsite ESRD 
survey activity to capture surveyor resources utilized.  For instructions on completion of 
Form CMS-670, refer to the State Operations Manual, Chapter 2, the Certification 
Process, Section 2705.   
 
2274D - Form CMS-2567: Statement of Deficiencies and Plan of 
Correction 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The Form CMS-2567: 
  Is the official report of survey findings;  
  Is the document which is disclosed to the public;  
  Details the facility's deficient practices identified during the survey; and  
  Contains the facilitys plan for correction. 
 
For more general information about the Form-CMS 2567, refer to the State Operations 
Manual, Chapter 2 the Certification Process, Section 2728.  For ESRD surveys, specific 
instructions regarding documentation on the Form CMS-2567 for the following V-tags are 
provided: 
Use of Tag V000 
This tag should be used to document the type of survey conducted (e.g., complaint, initial, 
revisit). 
Additionally, Tag V000 should include an explicit statement indicating the facilitys 
compliance, or level of non-compliance with the CfCs, as result of the survey findings.  
Finally, Tag V000 may also be used to list a glossary of technical terms and abbreviations. 
If listed at V000, the terms and abbreviations may be used throughout that CMS-2567 
without further explanation.   
Use of Tags V100, 101: State and Local Law 
The State determines compliance with its State licensure requirements.  Tags V100 and 
V101 may not be used to cite noncompliance with State licensure requirements unless the  state licensure finding has been completely adjudicated and is final, i.e., the finding has 
been upheld through the State appeals process or has not been appealed and is a final state 
action.   
Do not use V100 or V101 to cite deficiencies related to Occupational Safety & Health 
Administration (OSHA), the Americans with Disabilities Act (ADA), or the Food and 
Drug Administration.  CMS is not the designated entity to survey for those requirements.  
Refer concerns in these areas to the applicable CMS Regional Office for referral to and 
notification of the appropriate oversight entity.   
 
2274E - Form CMS-2567B: Post Certification Revisit Report 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The Form CMS-2567B is completed by the SA after a revisit survey to document 
verification of correction of deficiencies cited on the recertification survey. 
 
2274F - Form CMS-1539: Medicare/Medicaid Certification and 
Transmittal 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The SA uses Form CMS-1539 to communicate findings to the CMS Regional Office with 
respect to a facilitys compliance with health and safety requirements.  Form CMS-1539 is 
also a transmittal cover sheet for the certification packet.  The SA completes Part I of the 
form and the Regional Office completes Part II.  For instructions on completion of Form 
CMS-1539, refer to the State Operations Manual, Chapter 2 the Certification Process, 
Section 2762. 
 
2276 - SA Control of Form CMS-3427 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The SA date-stamps all Form CMS-3427s (End Stage Renal Disease Application and 
Survey and Certification Report) and application-related correspondence received and 
reviews the forms and documentation for accuracy and completeness.   
The SA forwards the original and one copy of Form CMS-3427, Part I, and the related 
materials to the RO within 3 days, using the Medicare/Medicaid Certification and 
Transmittal, Form CMS-1539 to forward their recommendation to the RO. 
 
2278 - ESRD Survey Procedures 
(Rev. 1, 05-21-04) 
 
2278A - Facility Withdraws Application Prior to Survey 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
If the surveyor arrives onsite and the facility states it no longer wishes to be considered for 
ESRD program participation, the SA requests that the facility immediately submit a 
statement of voluntary withdrawal electronically to the SA.  The surveyor should remain 
at the facility until the SA receives the request and instructs the surveyor to terminate the  survey. 
 
2278B - Certificate of Need (CON) 
 (Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Each application, except for a SPRDF, must be accompanied by evidence of a CON in all 
States where it is required by State law. 
 
The SA returns applications that do not include the CON on the basis of an incomplete 
application, using the model letter in Exhibit 30.  
 
2278C - Initial RO Approval 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
In order to be certified in the Medicare program as an ESRD facility, a facility must: 
 
  Complete Part I of Form CMS-3427A, End Stage Renal Disease Application and 
Survey and Certification Report;  
  Have provided care to a minimum of one patient per modality; and  
  Be in compliance with all federal requirements including the ESRD Conditions for 
Coverage 
  A certificate of need (CON), where required by State law, must be submitted by 
the facility unless it is a Special Purpose Renal Dialysis Facility (SPRDF).  
 
The SA forwards its recommendation for certification or for denial of certification to the 
CMS RO.  The RO will forward the final determination to the facility.  If the facility is 
approved for certification, the RO assigns the ESRD facility a CMS Certification Number 
(CCN) number and sends a Form CMS-2007 (Exhibit 156) to the MAC.  The RO 
completes the certification in ASPEN. 
 
2278D - Expansion or Addition of Services  SA/RO Procedures 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
When a facility submits a request for expansion of services, per form CMS-3427, this 
generally relates to the addition of dialysis stations.  The SA/RO will request and review a 
facility floor plan, with the proposed additional stations shown, to determine whether there 
are concerns regarding inadequate space for each station or infection control concerns due 
to inadequate space.  Since there are no square footage requirements for each station, the 
review must ensure that each station has adequate space to provide for patient privacy and 
sufficient space for safety such as providing the need for the patient to exit if necessary or 
for emergency care to be provided if necessary.   
If the review confirms there is adequate space for the expansion or addition of services, no 
on-site review is required.  The SA should notify the provider of the approval of the 
additional stations.   
When a facility submits a request for addition of a modality or service through the form 
CMS-3427:  1.  On-site survey must be performed for: (All applicable regulations for the 
service/modality requested should be reviewed.)  
  Addition of In-center Hemodialysis; (Survey confirms that the facility has 
provided HD to at least one patient.) 
  Addition of Home Training and Support Modality; (Survey must confirm 
that the facility has provided home training a support to a minimum of one 
patient.)  
  Addition of In-Center PD, if no approval for Home Training and Support; 
and 
  Addition of Reuse 
2.  On-site survey is not required for the following changes in modalities or services: 
  Addition of In-Center Nocturnal HD; (Provider must provide 
documentation how the water system will be maintained.)   
  Addition of In-Center PD, if facility already approved for Home Training 
and Support; and 
  Addition of HD or PD in a Long Term Care Facility, if already approved 
for Home Training and Support.) 
 
The SA notifies the facility of its decision regarding approval or denial of the expansion or 
addition.  If approval is recommended, the SA forwards a CMS-1539 to the CMS RO with 
a recommendation.  The RO forwards a CMS-2007 (Exhibit 156) to the MAC denoting 
any changes in services.  
 
2279 - ESRD CMS Certification Numbers 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The CMS Certification Number (CCN) is assigned to the ESRD facility after all 
certification requirements have been met.  Assignment of the ESRD facility CCN should 
be in accordance with the guidelines contained in Chapter 2 of the State Operations 
Manual, section 2779.A.1.  The RO forwards Form CMS-2007 to the MAC upon 
issuance of the CCN.   
ESRD facilities and their CCN series are as follows:  
  2300-2499 Hospital-Based Renal Dialysis Facilities  
  2500-2899 Independent Renal Dialysis Facilities  
  2900-2999 Independent Special Purpose Renal Dialysis Facilities  
  3500-3699 Satellite Renal Dialysis Facilities  
  3700-3799 Hospital-Based Special Purpose Renal Dialysis Facilities  
 
2280 - ESRD Survey Activities 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
State Licensure Requirements  An entity applying for certification as an ESRD facility must be in compliance with any 
applicable State Licensure requirements, in addition to the Federal requirements for each 
type of survey described below.  Although State licensure requirements may include State 
Certificate of Need (CON) for ESRD facilities, Special Purpose Renal Dialysis Facilities 
(SPRDFs) may be exempt from CON requirements.   
Initial Certification Application and Survey 
Application 
To request initial certification under Medicare, the applicant must notify the SA of their 
intent in writing, and submit Form CMS 3427: End Stage Renal Disease Application and 
Certification Report.  The SA will communicate with the applicant regarding all required 
documents that must submitted for enrollment and certification and inform the applicant 
that the facility must have provided services to at least one patient for each modality or 
service for which they are applying.  CMS will not accept the transfer of an already 
trained home dialysis patient or borrowing qualified home dialysis staff from another 
certified ESRD facility for initial approval of a Home Dialysis Training & Support 
program.  
 
The applicant must also submit Form CMS 855A: Medicare Enrollment Application: 
Institutional Providers to the Medicare Administrative Contractor (MAC).  Once the MAC 
reviews and approves the CMS-855A, it will notify the SA/RO that a survey may be 
scheduled.  
Prioritization of Initial Surveys 
The priority of initial certification surveys of prospective ESRD facilities is specified 
annually in the Survey and Certification Mission and Priority Document (MPD). 
 
Initial ESRD Certification Survey Process  
The ESRD initial survey should follow the ESRD Core Survey Process as discussed in 
Appendix H of the SOM. The ESRD survey process for initial certification includes a 
review of all ESRD Standards within the Conditions for Coverage.  
 
Initial Certification Determination 
The applicable CMS Regional Office is responsible for the initial certification 
determination of a new ESRD facility.   
 
Denial of Initial Certification 
If the initial certification survey identifies Condition-level non-compliance during an 
initial survey, the SA must notify the CMS Regional Office of the recommendation for 
denial of Medicare certification.  The State survey team must prepare the Form CMS 2567 
detailing the survey findings.  The CMS Regional Office reviews the findings and makes 
the final certification determination and then communicates its decision to the dialysis 
facility and to the SA, as well as notifies the MAC of the denial via Form CMS-2007.   
 
Reapplication after Initial Certification Denial or Voluntary Withdrawal 
In the case of voluntary withdrawal of a request for initial certification or a denial of 
certification, the facility may reapply in the future.  To reapply, the facility must resubmit 
a new Form CMS-3427 to the SA and a new CMS-855A to the MAC.  An initial survey 
will also be required.    
Recertification Survey 
Prioritization of Recertification Surveys 
Prioritization for recertification surveys of ESRD facilities is specified annually in the 
CMS Survey and Certification (MPD).   
 
Recertification Survey Process  
ESRD recertification surveys should follow the ESRD Core Survey Process as discussed 
in Appendix H of the SOM.  
 
Revisit Survey  
The SA must conduct a revisit survey prior to the termination date for any ESRD survey 
with findings of Condition-level non-compliance.  It is at the discretion of the SA/RO as 
to whether a revisit is performed when only Standard level deficiencies are identified.  The 
revisit survey is conducted to substantiate that the facility is back in substantial 
compliance with the applicable ESRD CfCs.  The SA schedules a revisit survey after the 
last date of correction provided in the approved plan of correction.  The information 
reviewed at the revisit is drawn from records and other evidence dated since the original 
survey.  It is the intent of the revisit survey to review compliance with requirements which 
were cited as being deficient on the prior recertification survey.  However, the surveyor(s) 
is required to cite any deficient practices identified in the course of determining correction 
of previously cited deficiencies,  
 
Temporary Closures 
A temporary closure may occur as a planned event (either voluntary or as the result of 
survey findings) to allow repair or remodeling, or as an unplanned event due to damage 
from a natural or man-made disaster.  The facility is required to notify the SA in writing of 
any temporary closure of the facility which extends greater than one day of operation.  
Prior to reopening, the facility must submit to the SA a description of the changes or 
modifications to the facility which occurred during the closure and must submit the results 
of product water quality testing performed after the restart of the water treatment system. 
This documentation must include chemical analysis, cultures, and endotoxin levels.  The 
SA will make a determination as to whether an on-site review is required based upon the 
submitted documentation.  In situations where the dialysis facility has damages caused by 
a natural or man-made disaster which affects, or has the potential to affect the structural 
integrity of the facility, an on-site survey shall be performed prior to re-opening.  
 
The SA must review the facility-submitted information and determine whether the water 
testing results (if applicable) are within acceptable limits, as detailed in the ESRD CfCs at 
42 CFR 494.40(a) (see V177, V178 and V180), and notify the facility administrative 
personnel whether or not the water testing results are within the requirements of the 
regulation and may reopen to treat patients. 
If, in the course of repair or remodeling during a temporary closure, the facility determines 
that it is more expedient to relocate, the facility must immediately communicate this 
request to the SA.  The SA must evaluate the request and determine whether the ESRD 
facility will retain their participation at the new location.  The SA would then follow the 
relocation process described below.    A temporarily closed facility may not retain its Medicare participation indefinitely.  At the 
time of the temporary closure, the facility provides a projected date for resumption of 
services.  The projected time frame for closure must be consistent with the repairs or 
renovation required.  Depending on the duration, closure may be viewed as a cessation of 
business (voluntary termination of the Medicare CCN).  The facility may be asked to 
submit periodic progress reports to the SA as to whether the projected re-opening remains 
the same.  
Relocation Survey 
Generally, a relocation survey is not required when an ESRD facility relocates to a new 
physical location but is still serving the same patients and employing the same staff, 
changes its location on a campus or changes its location within the original address.  
However, the ESRD facility must submit the following information to the SA and an on-
site survey may be performed if indicated by the information submitted: 
 
Prior to the move, the ESRD facility must inform the SA how patients will continue to 
receive dialysis treatments uninterrupted during the relocation.  
Immediately upon the relocation the ESRD facility must submit evidence to the SA that 
water testing was performed and determined to be within acceptable ranges.   
The ESRD facility must also submit a revised floor plan to the SA to confirm adequate 
space for stations.  
Criteria for Relocations 
If a dialysis facility permanently relocates, it must remain essentially the same operation at 
its new location.  CMS makes the determination that the facility is serving the same 
patients with the same staff.   
 
Process for Relocations  
A dialysis facility must notify the SA prior to its relocation and notify the Medicare 
contractor (MAC) via a revised CMS-855A within 90 days following the move.  The 
facility must submit a revised Form CMS-3427 to the SA.  The facility must immediately 
inform the SA of any changes to the relocation date.   
 
Prior to the relocation of any patients, the facility must provide reports to the SA 
demonstrating acceptable results of product water quality testing, including chemical 
analysis and reports of acceptable results from testing for bacteria and endotoxin at the 
new location.  If additional or replacement dialysis machines will be used in the new 
location, documentation must be submitted to confirm that baseline dialysate, bacteria and 
endotoxin have been completed on those machines.  The facility must provide a floor plan 
to confirm sufficient space and privacy for each station.  The facility must also attest to 
compliance with the Life Safety Code requirements.  The SA reviews the reports and the 
floor plan to ensure the results are within acceptable limits, as detailed in the ESRD CfCs 
at 494.40(a) (see V177, V178 and V180).  Once the SA accepts these water and dialysate 
quality reports and completes any indicated on-site review, the SA notifies the facility that 
it may open and operate the same number of treatment stations approved at its previous 
location and relocate its patients.  If the facility requests additional stations concurrent 
with the relocation, see instructions below for Expansions.   
In the event that the ESRD facility relocates without notifying the SA and does not submit 
the above referenced documentation and information to the SA before relocating patients,  the SA should conduct an immediate jeopardy complaint investigation to ensure that water 
testing has been done appropriately, there is adequate space for the stations, and Life 
Safety Code requirements are met.   
If the ESRD facility requests approval for an additional service or modality 
simultaneously with a relocation, refer to SOM Section 2278D regarding Expansions and 
Change in Services to determine whether an on-site review is required. 
Certification at the New Location 
If an ESRD facility relocates to another state, it is considered a voluntary termination and 
the facilitys Medicare CCN is terminated. The relocated facility must seek Medicare 
participation as an initial applicant in the new State.  The ESRD facility would be certified 
as a new ESRD facility and have a new CCN once it demonstrates compliance with all 
federal requirements. 
 
If an independent ESRD facility relocates within the same state, the CMS RO will 
determine if the facility will retain its Medicare agreement and CCN after the relocation, 
or whether the move will be treated as a cessation of business (voluntary termination) of 
the first location and an initial certification of a prospective ESRD facility at the new 
location.  The RO will base its decision on whether the ESRD facility continues to serve 
the original community and utilizes the same staff after the relocation as it served at the 
previous location.  
If a hospital-based ESRD facility relocates to an off-campus location but continues to 
serve the same community and utilizes the same staff at this new location, its CCN will be 
retired and the facility will be assigned a new CCN that corresponds to renal satellite 
facilities. This is not a voluntary termination. 
Expansions and Change in Modalities and Services 
Expansion: Addition of In-Center Dialysis Stations 
When a dialysis facility wishes to increase the number of its approved in-center dialysis 
stations, it must submit a new Form CMS-3427 ESRD Application and Survey and 
Certification Report to the applicable SA.  The dialysis facility must specify the number of 
additional stations requested and include: evidence that adequate space is available for the 
stations in consideration of safety and infection control; and a summary explanation of any 
building renovations that will be necessary for the addition of stations. 
 
Voluntary elimination of approved modalities/services 
When a dialysis facility wishes to discontinue providing an approved dialysis modality or 
dialyzer reprocessing/reuse, it must file a new Form CMS 3427 reflecting the 
modalities/service that it plans to provide after the elimination along with a written 
explanation of the change(s).  When received, the SA must review the information and 
contact the facility with any concerns or additional information required, such as plans for 
appropriate transition of patients who rely upon the discontinued service.   
 
To assure patient access to care in the community served by the dialysis facility, when a 
facility wishes to eliminate a dialysis modality, the change should not inconvenience 
patients.  If a facility has one or more patients in their patient census who is using the 
dialysis modality it plans to eliminate, the facility must: 
  Assess each patient who will be affected by the change (494.80(a));    Inform the affected patients of the plan to eliminate the modality, and of their 
options for continuing treatment (e.g.  transfer to a facility that offers the modality, 
switch to a different modality offered by the current facility) (494.70(a), 
494.70(b)); 
  Include the affected patients in the decision-making process, giving weight to the 
patients preferences for their continued care (494.80(a)(9)); and 
  Arrange for orderly transfer of those patients who opt to transfer to another 
facility.  The facility must report to the applicable ESRD Network any patient 
transfer when the patient(s) feels that he/she was transferred without their consent 
(involuntary transfer). 
 
The SA must also communicate with the applicable ESRD Network to confirm that the 
facility gave the affected patients sufficient (30 days) notice that the service was to be 
discontinued and that the patients are relocated to other ESRD facilities in consideration of 
patient preferences and with minimal disruption.  If the SA identifies concerns with any of 
the above protections, a deficiency may be cited at 494.70(a) and/or 494.70(b). 
Addition of dialysis modalities or services 
When a facility wishes to add a dialysis modality or service, it must file a revised Form 
CMS-3427 with the applicable SA office.  Upon receipt of the form, the SA must review 
the facility file, if available, for current or past quality concerns, the current FY State 
Outcomes List, and must contact the applicable ESRD Network.  The SA should utilize 
this information to assist with an on-site review, where required.  Refer to section 2278D 
for guidance on addition of dialysis modalities or services.  The SA informs the facility 
that it must have at least one patient on census using each dialysis modality for which it is 
applying to allow the SA to review care.   
 
For approval of each home dialysis modality for which the facility is applying, there must 
be at least one patient and/or their caregiver, on census who is in the process of being 
trained or has been trained by that facility.  CMS will not accept the transfer of an already 
trained home dialysis patient or borrowing qualified home dialysis staff from another 
certified facility.  Such a practice does not constitute evidence that the facility meets the 
requirements to demonstrate that it will continue to provide safe and effective care for 
these patients on an ongoing basis. 
Complaint Survey 
When investigating complaint allegations or the circumstances of a self-reported event in 
an ESRD facility, the ESRD surveyor should use all applicable survey tasks or portions of 
tasks from the ESRD Core Survey process at Appendix H of this SOM.  See Chapter 5 of 
the SOM for additional instructions on complaint investigations.  
 
Extension of a Complaint Investigation into Recertification Survey 
When the findings from a complaint survey are determined to be at Condition-level or the 
surveyor identifies an Immediate Jeopardy situation, the SA must extend the complaint 
survey into a full recertification survey.   
 
Change of Ownership (CHOW) 
Refer to SOM Section 3210   
2281 - Waivers 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
2281A - Isolation Room Waiver 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The ESRD CfCs at 494.30(a)(1)(i) refer to the requirements for the treatment of 
hemodialysis patients who are positive for hepatitis B (HBV+).  Every certified ESRD 
facility must have the capacity to treat one or more HBV+ patients in an isolation room or 
isolation area, or have an approved waiver under 494.30(a)(1)(ii).   
 
An isolation room is a separate room with walls and a door to contain any spatter of 
blood, body fluids or other contaminants.  The door does not need to remain closed, 
except as indicated to contain contaminants.  The walls do not need to reach the ceiling, 
but should be a least six feet in height and must fully contact the floor to contain blood 
spills.  The walls must allow for continuous visualization of the patient(s) in the room.  
Plexiglas (or similar) walls are acceptable. 
 
An isolation area is an area or space separated from other dialysis stations by a space 
equivalent to the width of a hemodialysis station. 
Sufficient capacity takes into account the availability of dialysis facilities with isolation 
rooms in the proximate geographic area.  The proximate area must not create an undue 
hardship on the patient to have to relocate to the proximate facility.   
ESRD facilities certified prior to February 9, 2009 may have an isolation area, an isolation 
room or apply for an isolation room waiver to provide isolation services.  In those 
instances where a patient already being served by the ESRD facility develops the need for 
isolation, the ESRD facility must have written arrangements in place to affect the safe 
transfer of the patient to another local ESRD facility which does provide isolation 
services.  
Facilities certified after February 9, 2009 must have either an isolation room or apply for 
an isolation room waiver to provide isolation services. In those instances where a patient 
already being served by the ESRD facility develops the need for isolation, the ESRD 
facility must have written arrangements in place to affect the safe transfer of the patient to 
another local ESRD facility which does provide isolation services.  
Waiver Process 
Under 494.30(a)(1)(i), a new or expanding dialysis facility may be eligible for a waiver 
of the isolation room requirement if isolation rooms for HBV+ patients in other ESRD 
facilities are available and the available HBV+ isolation rooms sufficiently serve the needs 
of the HBV+ patients in the geographic area. 
 
The facility must update the CMS-3427 form by completing Field 26 to annotate the 
waiver request.   The facility must submit a written request for an isolation room waiver to the applicable 
SA.  The written request must include information about the geographical proximity of 
facilities with isolation rooms and identifies any barriers to accessibility for the patients.   
The SA makes a recommendation via Form CMS-1539 to the RO for approval or denial of 
an isolation room waiver request.  Document in the Remarks section the request for a 
waiver of the isolation room requirement.  The CMS RO will review the information, 
make the decision whether to grant the waiver, and inform the facility and the SA of its 
decision. 
 
Criteria for Consideration of the Isolation Room Waiver: 
1)  Other facilities in the local area that provide isolation services (review CMS-3427 
Forms to verify if the facility provides isolation services); 
2)  Communications with the ESRD Network regarding geographical availability of 
isolation services, quality of care concerns involving isolation, etc.;  
3)  Complaints received by the SA regarding lack of isolation services provided.  
 
2281B - Medical Director Waiver 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The ESRD CfCs at 494.140(a)(1) require dialysis facilities to have a qualified medical 
director and specifies the qualification criteria.  A qualified medical director must have 
completed a board-approved training program in nephrology; have 12 months of 
experience providing care to dialysis patients; be licensed to practice in the State; and be 
board certified in internal medicine or pediatrics.   
 
If a qualified physician is not available to serve as the medical director of a certified 
dialysis facility, the ESRD CfCs at 494.140(a)(2), provide that another physician may 
direct the services subject to the approval of the Secretary.  
Waiver Process  
Waiver of the medical director requirement is not available for initial certifications.  
 
For existing facilities, if a physician who meets the required qualifications at 
494.140(a)(1) is no longer available to serve as medical director of a certified dialysis 
facility, a facility may request a waiver to appoint  another physician to serve as the 
medical director. This request must be reviewed and approved by CMS.  
 
The facility request for waiver consideration, along with a brief resume of the alternate 
physician and an explanation as to why a physician who meets the requirements is not 
available should be submitted to the applicable SA.   
 
The SA forwards the waiver request along with their recommendation for approval or 
denial via CMS-1539 to the RO.  The CMS RO makes the final determination on 
approval/denial.    Criteria for Consideration of the Medical Director Waiver: 
1)  Facility ranking on the most recent confidential outcomes list is at or above the 
national five percent threshold; 
2)  Lack of qualified providers in the geographical area; 
3)  Impact of a waiver denial on patient access to care; 
4)  Candidates previous experience in the care of dialysis patients;  
5)  Continuing efforts of the facility to secure a qualified medical director.  
Waivers should be reviewed by the RO on an annual basis.  The RO requests the facility 
to submit updated information addressing 1-5 of the considered criteria above for the 
annual review.  
The CMS RO will review the request, make the decision, and inform the facility and the 
SA of its decision regarding the waiver request.   
The current Master list of approved ESRD facility waivers can be found on the CMS 
Quality Certifications and Oversight Reports (QCOR) web site under Resources in the 
menu bar, and listed under ESRD Waivers Tracking Worksheets MASTER. (QCOR) 
 
2281C - Life Safety Code Waiver 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Limited LSC Applicability  Exemption for certain ESRD Facilities 
Effective July 16, 2012, pursuant to 494.60 (d)(1), compliance by certified ESRD 
facilities with the applicable requirements of the 2000 edition of the National Fire 
Protection Association (NFPA) Life Safety Code 101 is limited to those ESRD facilities 
that are located adjacent to high hazardous occupancies and those facilities that do not exit 
to the outside at grade level from the patient treatment area.   
 
Exit to the Outside at Grade Level from the Patient Treatment Area Level:  
The phrase exit to the outside at grade level from the patient treatment area level applies 
to ESRD facilities that are on the ground or grade level of a building where patients do not 
have to traverse up or down stairways within the building to evacuate to the outside.  
Accessibility ramps in the exit area that provide an ease of access between the patient 
treatment level and the outside ground level are not considered stairways.  Compliance 
with the structural requirements of NFPA LSC 101 for ESRD facilities that pose a higher 
risk for life safety from fire is still required.  Such higher risk ESRD facilities include 
those that do not have a readily available exit to the outside at grade level for swift, 
unencumbered exit and those facilities that are located adjacent to an industrial high 
hazardous occupancy, as defined by NFPA 101 at section A.3.3.134.8.2, Annex A. 
 
Defining Adjacent to an Industrial High Hazardous Occupancy:  
An industrial high hazardous occupancy is based upon the definition in the NFPA LSC 
101, 2000 Edition at section A.3.2.134.8.2, Annex A as: occupancies where gasoline and  other flammable liquids are handled, used, or stored under such conditions that involve 
possible release of flammable vapors; where grain dust, wood, or plastic dusts, aluminum 
or magnesium dust, or other explosive dusts are produced; where hazardous chemicals or 
explosives are manufactured, stored, or handled; where cotton or other combustible fibers 
are processed or handled under conditions that might produce flammable flyings; and 
where other situations of similar hazard exist. Being adjacent means an ESRD facility 
shares a common wall, floor, or ceiling with that occupancy. 
 
The ESRD facility administrator may submit an attestation to the applicable SA that the 
facility meets the requirements for an exemption to compliance with NFPA LSC 101.  
Those facilities that do not submit an attestation claiming exemption will be considered a 
non-exempt facility and will continue to be surveyed for compliance with chapters 20 and 
21 of the NFPA 101 LSC, 2000 Edition. 
 
2282 - RO Use of Provider Tie-In Notice, Form CMS-2007, for Suppliers 
of ESRD Program Services (Exhibit 156) 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Form CMS-2007 serves as the official notice to the MAC of program actions affecting 
ESRD facilities that supply Medicare program services. The RO must forward a CMS-
2007 to the MAC for all initial certifications/denials, voluntary and involuntary 
terminations, and CHOWs.  The addition of a new service or modality must be 
communicated with the MAC and may be forwarded through either the CMS-2007 or 
electronic mail.  
 
 
2283 - Termination Procedures  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
See SOM Chapter 3. 
 
2284 - Specialized Areas of ESRD Oversight 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
 
2284A - Centralized Dialyzer Reprocessing 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Centralized dialyzer reprocessing refers to a process of transporting used hemodialyzers 
from multiple facilities to a central location for reprocessing.  When centralized 
reprocessing services are used, the certified dialysis facility retains responsibility for the 
dialyzer reprocessing, is expected to actively communicate and coordinate with the 
centralized reprocessing entity, and incorporate the activities of the centralized 
reprocessing location into the dialysis facilitys Quality Assessment and Performance 
Improvement (QAPI) oversight of the dialyzer reprocessing/reuse program. 
On-site visits to centralized reprocessing sites are done as a part of the survey of any  dialysis facility using a reprocessing site, since there is no separate Federal certification 
for centralized reprocessing sites.  Some States may have licensing requirements for these 
sites.  The ESRD CfC requirements at 42 CFR 494.50 for the dialyzer reprocessing area, 
reprocessing procedures, environmental control, safety standards, and training of staff are 
the same for the centralized reprocessing site as for on-site dialyzer reprocessing at the 
ESRD facility.  An on-site review of the reprocessing center must be included in every 
initial and recertification survey.   
When a facility utilizes a central reprocessing service, there must be clear policies to guide 
the transporting of the dirty (i.e., used) dialyzers to the reprocessing site and returning the 
reprocessed dialyzers to the dialysis facility for clinical use.  The system for transportation 
of the dirty dialyzers must protect patients dialyzers from damage and microbiological 
contamination. Temperature controls must be in place to prevent microbiological growth, 
container temperatures monitored during transit, and steps taken to prevent cross-
contamination between dialyzers during transport ( 494.50(b)(1) at V319, V331, and 
V345).  Safety checks must be in place to assure that reprocessed dialyzers are returned to 
the correct ESRD facility for use. Culture and endotoxin testing must be conducted at least 
monthly at the centralized reprocessing site and results monitored and retained at user 
dialysis facilities ( 494.40(a) at V178;  494.50(b)(1) at V314).  User dialysis facilities 
must include oversight of the centralized reprocessing location outcomes, equipment 
maintenance, staff competency verifications, and other applicable Reuse Quality 
Assurance audits in their QAPI program ( 494.110(a)(2)(vii);  494.50(b)(1) at V360-
368). 
Deficiencies Identified at the Centralized Reprocessing Location 
During the on-site visit to a centralized reprocessing location, the surveyor obtains a list of 
the names and CCNs of all Medicare certified dialysis facilities currently using the center.  
If any deficiencies are cited during the on-site visit at the reprocessing center, the SA must 
secure corrective action from all ESRD facilities within their jurisdiction.  Each ESRD 
facility, including the ESRD facility under survey, is immediately notified of the findings 
and the need for a corrective action plan.  The SA must contact the affected ESRD 
facilities not under survey by electronic mail or telephone the day the finding is made.  
The findings are then cited on a CMS-2567 for all facilities within the SAs jurisdiction 
that utilize the center.  Upon return to the SA, the finding is entered into ACTS as a 
complaint against all ESRD facilities not under survey and a CMS-2567 is issued to each 
facility with a plan of correction requested.    
The SA notifies the applicable State Health Department of the findings as required by 
Revised S&C 14-36.   
When survey findings at a reprocessing center identify ESRDs from other states utilizing 
the center, the SA should notify their RO that will in turn notify the other ROs for the 
affected states and the associated SAs will prepare the CMS-2567s.   
 
2284B - ESRD Services across State Lines 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
There are instances when a certified dialysis facility will provide home hemodialysis or  home peritoneal dialysis services to patients or nursing home residents who reside within 
close proximity of state lines (which in some cases may be across the street).  No special 
approval or agreement is required for a dialysis facility to provide home training and 
support services to patients in a bordering states.  
 
2286  ESRD Network Participation and Data Submission 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
2286A  ESRD Network Participation 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
There are 18 geographically-defined ESRD Networks (NW) across the United States.  
Every dialysis facility is located within the service area of an ESRD NW.  ESRD facilities 
must cooperate with their assigned NW and participate in NW activities.   
 
ESRD NWs are contracted by CMS to advance quality improvement in dialysis facilities 
through monitoring and supporting facility-based participation in quality improvement 
activities which ensure safe, effective care.  CMS expects ESRD NWs to address and 
attempt to resolve patient grievances and to facilitate clinical data submission and 
analysis.  To ensure the cooperation of dialysis facilities in achieving the CMS goals 
assigned to ESRD NWs, each facility is required to sign a NW/Facility agreement as part 
of their initial certification.   
CMS expects SAs and ESRD NWs to establish an ongoing relationship focused on the 
provision of quality care and the advancement of quality improvement in the ESRD 
facilities.  The relationship should include regular communication and coordination 
between the SA and the ESRD NW regarding routine quality improvement activities as 
well as ad hoc communication and collaboration as indicated when individual facilities 
have serious quality concerns that could impact the health and safety of patients.   
 
Surveyors should contact the ESRD Networks prior to beginning a survey to gather 
facility information, but only after entering the ESRD facility and beginning the survey to 
ensure the survey remains unannounced.  Surveyors should contact the NW before 
initiation of the facility Environmental Flash Tour.  Surveyors should inquire whether 
the NW has information to share regarding quality concerns, patient complaints, 
involuntary discharges, and/or involuntary transfers.  It is important that surveyors observe 
the protocols designed to ensure that surveys are unannounced and unpredictable, while 
also gathering information important to the survey process.   
 
2286B - Furnishing Data and Information for ESRD Program 
Administration (42 CFR 494.180(h)) 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18)  
 
All certified, participating ESRD facilities must furnish data and information to CMS as 
specified by the Secretary, pertaining to its ESRD patient care activities and costs.  The national 
End-Stage Renal Disease Program Management and Medical Information System (ESRD-
PMMIS) collects information from each participating ESRD facility. 
  2286C  Using ESRD Data 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Surveyors are expected to use Dialysis Facility Reports (see below) to inform the ESRD 
survey process.  This report provides aggregate data regarding laboratory values, 
demographic information, mortality rates, hospitalizations, infections, etc. which may 
assist the surveyors during the review of patient medical records.   
 
2286C.1 - Dialysis Facility Reports and Outcomes Lists 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Each SA and CMS RO assigns a Master Account Holder to control access to the State-
specific data which are available on the CMS ESRD Dialysis Facility Reports website.  
The State Master Account Holder is responsible for accessing the State-specific data at the 
beginning of each fiscal year.  ESRD data reports on this site include: 
 
  A State Profile, which provides an overview of the State-specific outcomes and 
general information such as the number of facilities and number of patients 
receiving dialysis in the State; 
  An Outcomes List, which includes all certified dialysis facilities in the State 
ranked according to selected outcomes, with the facility which has the poorest 
outcomes listed first; 
  A Dialysis Facility Report (DFR) for each dialysis facility in the State; and 
  An ESRD Core Survey Pre-survey DFR Extract Report for each dialysis 
facility in the State, which lists key data elements to facilitate pre-survey 
preparation. 
 
Each SA must:  
  Review the State profile to determine specific problem areas in each State, 
including but not limited to failure to meet expectations regarding infection control 
practices; 
  Use the State rank-ordered Outcomes List and the data profiles, in conjunction 
with other information, to select the facilities to be surveyed;  
  Use the facility-specific Dialysis Facility Reports before each survey to inform 
survey activities; and 
  Use the ESRD Core Survey Pre-survey DFR Extract Report to facilitate surveyor 
review of key facility outcomes and trends for comparison to national benchmarks 
in preparation for surveys regarding potentially problematic clinical areas in that 
facility. 
 
The CMS Dialysis Facility Reports web site has a section that is open to the public and a 
section that is password protected.  No password is required to access the list of Master 
Account Holders and sample reports (Dialysis Facility Report, Supplemental Report, and 
State/Regional Profile) and guides to those reports.  The password protected section of the 
web site is: 
  For surveyors,     Controlled by Master Account Holders for each State/Region, and  
  Contains the Dialysis Facility Report and DFR Extract Report for each dialysis 
facility; the Outcomes List for each State; and the State/Regional Profiles.   
 
2286C.2 - Dialysis Facility Compare 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Dialysis Facility Compare is a site intended for public use and includes a tool for locating 
and comparing dialysis facilities in an area.  This site offers information about Medicare-
certified dialysis facilities and other resources for patients and family members who want 
to learn more about chronic kidney disease and dialysis, or to compare the services 
available in area dialysis facilities, and the quality of care that those facilities provide.  
Dialysis Facility Compare uses the same data sources as the Dialysis Facility Reports and 
provides additional information and resources for patients and families. 
 
2287 - ESRD Patient Care Technician (PCT) 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
2287A - PCT Certification 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Per 494.140(e), PCTs hired prior to October 14, 2008, should have attained their PCT 
certification by April 15, 2010. PCTs hired after October 14, 2008 must attain the PCT 
certification within 18 months of their date of hire. CMS counts all PCT work experience, 
regardless of changes in employer, in determining the 18-month time period allowed for 
completion of PCT certification.  An approved leave of absence (medical/military/other) 
extends the period by the number of full or partial months of the leave of absence.  If a 
PCT does not work as a PCT in any dialysis facility for 18 months or more, the 18-month 
time period allowed for completing certification begins anew. 
2287B - Definition of a PCT 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
The CMS requirement for PCT certification applies to unlicensed individuals providing 
direct patient care.  PCTs may be described in a variety of terms, including biomedical 
technician and dialysis assistant. For purposes of CMS technician certification 
requirements, a dialysis PCT is any unlicensed staff member who has responsibility for 
direct patient care.  Direct patient care is defined as any aspect of healthcare for a 
patient provided personally by a staff member, including but not limited to collecting data 
(e.g., vital signs, weights, symptoms since last treatment), setting up the dialysis machine, 
testing reprocessed dialyzers for the presence or absence of germicide, 
initiating/terminating treatment, care of the dialysis access, delivering any aspect of the 
hemodialysis or peritoneal dialysis process, responding to machine alarms, and 
administering medications as allowed by State practice acts.  A person who only 
reprocesses dialyzers and/or maintains or takes down dialysis machines (removes 
dialyzer and lines from the machine after use) and who has no direct patient care  responsibilities is not considered a PCT by CMS. 
 
2287C - Certification and Additional Requirements  
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
In addition to being certified by a nationally recognized certification organization 
program, PCTs must meet applicable Federal and State requirements for education, 
training, and competency to provide patient care in dialysis facilities.  This includes any 
State requirements related to practice standards, certification, credentialing, licensure, or 
registration.   
 
ESRD CfC requirements at 42 CFR 494.140(e), which became effective on October 14, 
2008, requires that the PCT have a high school diploma or equivalency (GED).  
Recognizing that there were PCTs with extensive experience working in dialysis facilities 
as of the effective date of the ESRD CfC who may not have verification of a high school 
diploma or GED, PCTs with greater than four years of PCT work experience in dialysis as 
of the effective date were permitted to use that work experience in lieu of the requirement 
for a high school diploma or GED until April 15, 2010.  Any PCT applying for 
certification after April 15, 2010 must have a proof of high school diploma or GED.   
 
CMS also requires that PCTs complete an RN-directed, medical director-approved, job-
specific training program which includes the curricula prescribed by the ESRD CfC at 42 
CFR 494.140(e)(3) before independently providing care to dialysis patients. 
 
 
 
 
2287D - State and National Certification Programs for PCTs 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
PCT certification can occur under the aegis of either a State or National PCT certification 
organization.  Usual components of the State and National programs include:  
  A qualifying standardized test;  
  An independently proctored and protected testing environment; 
  Ongoing re-certification.   
 
There are currently three recognized National organizations providing commercially-
available PCT certification programs: the Board of Nephrology Examiners for Nursing 
and Technology (BONENT), the Nephrology Nursing Certifying Commission (NNCC); 
and the National Nephrology Certification Organization (NNCO).   
 
2288 - Infection Control Considerations 
(Rev. 181, Issued: 09-21-18, Effective: 09-21-18, Implementation: 09-21-18) 
 
Saline Flush Syringes 
  Under 42 CFR 494.30(b)(2), ESRD facilities must follow aseptic technique when 
preparing and administering intravenous medications; including the filling of syringes 
with sterile saline for use during the dialysis procedure.  
 
Pursuant to current recommendations from the Centers for Disease Control (CDC), ESRD 
facilities may not fill syringes with saline from the single dose saline bag or IV tubing 
connected to the patient at the dialysis station.  To comply with recommended safe 
injection practices, the facility may acquire pre-filled syringes or may prepare saline 
syringes for an individual patient in a clean area away from the patient treatment area.  
When saline syringes are required for vascular access care or to flush medications, ESRD 
facilities should obtain syringes pre-filled with sterile saline from a manufacturer, Food 
and Drug Administration (FDA) registered outsourcing facility, or pharmacy whenever 
possible.  However, when saline syringes must be prepared in an ESRD facility for 
administration, the following safe injection practices must be followed: 
 
  Fill syringes with sterile saline for an individual patient in a dedicated clean area 
removed from the patient treatment area.  Although not required, a clean room 
separate from the patient treatment area is the preferred location.  
  Prepare syringes for an individual patient as close as possible to the time of 
administration to prevent compromised sterility or stability.  
  Use aseptic technique for disinfection of saline vials prior to entry and follow the 
suggested standards from the Association for Professionals in Infection Control 
and Epidemiology (APIC) and the Institute for Safe Medication Practices (ISMP) 
when preparing saline flushes including:  
  Medication containers labeled single-dose or single-use (e.g., saline bags, 
o
single- dose vials, ampules) may not be used to prepare more than one 
syringe for vascular access care or to flush medications.  Any unused saline 
in the opened single-dose or single-use container must be discarded and 
may not be stored for future use on the same patient.  
  If multi-dose vials are used to prepare saline flush syringes, they must be 
o
dated upon opening and discarded within 28 days unless the manufacturer 
specifies a different date for that vial. The beyond-use date should never 
exceed the manufacturers expiration date.  
 
Cleaning the Dialysis Station 
According to current recommendations from the CDC, to prevent cross-contamination 
between dialysis patients, it is important that the previous patient completely vacate the 
dialysis station before the ESRD staff begins cleaning and disinfection of the station and 
set up for the next patient.  Surveyors should cite 42 CFR 494.30(a)(4)(ii) if 
noncompliance with cleaning and disinfection of the dialysis station is identified during 
the survey. It is important to note that all dialysis patients must be clinically stabilized 
(i.e., stable blood pressure, vascular access hemostasis) following their dialysis treatments 
before being moved from the dialysis station.  If a patient is not sufficiently stable to be 
moved from the dialysis station, cleaning and disinfection of the equipment at the station 
and preparations for the next patient must be delayed until the patient is able to be safely 
moved outside the station. 
  Providers of Outpatient Physical Therapy and/ or Outpatient  
Speech Pathology Services Specified in  485.701-485.729 
 
2290  Providers of Outpatient Physical Therapy and Speech-Language 
Pathology Services - Citations 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
The statutory basis for providers of outpatient physical therapy and outpatient speech-
language pathology services is found under  1861(p) of the Social Security Act.  The 
Conditions of Participation (CoPs) for rehabilitation agencies, clinics (operated by 
physicians) and public health agencies as providers of outpatient physical therapy and 
speech-language pathology services, are specified in 42 CFR Part 485, Subpart H.  
Appendix E of the State Operations Manual (SOM) and sections 2290-2306 of the SOM 
contain interpretive guidelines for regional offices (ROs), State Agencies (SAs) and 
accreditation organizations (AOs). 
 
2292 - Types of Organizations, Who May Provide Outpatient Physical 
Therapy and Speech-Language Pathology Services, Specified in  
485.701-485.729 
(Rev.83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
There are three types of organizations that may qualify as providers of outpatient physical 
therapy and speech-language pathology services under 42 CFR Part 485, Subpart H: 
clinics, public health clinics, and rehabilitation agencies.  However, rehabilitation agencies 
are the only organizations that are currently enrolled as a Medicare provider with a CMS 
Certification Number (CCN).  The general term organization is defined as a clinic, 
rehabilitation agency, or public health agency and is used throughout this chapter and the 
interpretive guidance to collectively reference these providers of outpatient therapy 
services (i.e. outpatient physical therapy and speech-language pathology that were 
formerly referred to as OPTs).  Any specific organization, such as a rehabilitation agency, 
will be noted in the guidance as appropriate for requirements that are specific to that 
organization alone. 
 
2292A - Rehabilitation Agency 
(Rev.83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
The primary purpose of a rehabilitation agency is to improve or rehabilitate an injury or 
disability, and to tailor a rehabilitation program to meet the specific rehabilitation needs of 
each patient referred to the agency.  A rehabilitation agency must provide, at a minimum, 
physical therapy and/or speech language pathology services to address those needs of the 
patients.  Social/vocational services are no longer a requirement. 
 
The rehabilitation agency must be able to provide therapeutic procedures as well as the 
modalities of heat, cold, water and electricity for physical therapy treatments for the 
patients it accepts for service at any of its practice locations.  The rehabilitation agency 
must also be able to provide any equipment required by the speech-language pathologist to  treat patients accepted for such service. 
 
As noted above, rehabilitation agencies must provide at least physical therapy and/or 
speech language pathology services to comply with the CoPs.  Occupational therapy is an 
optional service and cannot be substituted for either of these two services. It may be 
provided in addition to physical therapy and/or speech-language pathology services. 
 
A rehabilitation agency is no longer required to have a physician on call to furnish 
necessary medical care in case of an emergency.  However, the rehabilitation agency must 
have policies and procedures in place that instruct its staff regarding the steps to take in an 
emergency (including notification of the patients doctor) and appropriate documentation. 
Refer to 42 CFR 485.711(c). 
 
2292B  Rehabilitation Agency, Clinic and Public Health Agency 
(Rev. 150, Issued: 10-30-15, Effective: 10-30-15, Implementation: 10-30-15) 
 
Two person duty requirement: Organizations must always have at least two persons 
(either of its own personnel or its contracted personnel) on duty on the premises anytime 
rehabilitation treatment is being provided to a patient. The two person requirement does 
not specify which staff must be on duty (in other words, professional staff or a 
combination of professional staff and support staff), but the organizations must consider 
the supervision required of support staff. 
 
This duty requirement can be verified by requesting staff or personnel time cards. The 
staff time cards can be compared against patient sign-in sheets if there are concerns 
regarding the two person duty requirement. 
 
Services provided in a patients residence are exempt from the two person duty 
requirement. Additionally, services provided in a patients room within an assisted living 
facility (ALF) or independent living facility (ILF) may be considered to be a patients 
residence and therefore also exempt from the two person on duty requirement.  A common 
or general use area of the facility, such as a hallway, may be considered to be an extension 
of the patients room and residence and also exempt from the two person on duty 
requirement. 
 
This requirement is for the safety of the patients. It is not a new requirement, but is 
sometimes overlooked, particularly at a rehabilitation agencys extension location(s). 
Refer to Interpretive Guidance Tag I-118 in Appendix E of the SOM. 
 
Supervision: A physical therapist may not supervise an occupational therapy assistant, 
nor, may an occupational therapist supervise a physical therapist assistant. 
Nonprofessional personnel (generally physical and occupational therapy aides) cannot be 
supervised by anyone other than the qualified physical or occupational therapist while 
performing patient care activities. 
 
Clinical records: The regulations at 485.721 require clinical records be maintained on 
all patients served by the organization.  A copy of the patients current clinical record  should be kept at the practice location and readily accessible for prompt retrieval. 
Electronic records are acceptable but should be password or other method protected to 
maintain security and patient privacy. 
 
Administrator: The administrator (485.709) is given internal control of the clinic or 
rehabilitation agency by the governing body. The administrator must assume overall 
administrative responsibility for the entirety of the organizations operation including 
extension locations and/or off-premises activities. Furthermore, the administrator must 
serve as a full time administrator, meaning he can only be responsible for a single 
Medicare certified organization. It is important to determine whether the administrator can 
efficiently and effectively serve as administrator if the agency has several extension 
locations. Also, a competent individual must be available at each extension location to 
manage the day to day operations of that location on the days when the administrator is 
not onsite. That individual is responsible for reporting to the administrator. 
 
Governing body: The governing body ( 485.709) (or designated person so functioning) 
has the legal responsibility for the overall clinic or rehabilitation agency operations 
(including conduct and compliance of the clinic or rehabilitation agency) and may be 
legally responsible for more than one clinic or rehabilitation agency. The governing 
bodys legal responsibility for the overall conduct of the clinic or rehabilitation agency 
cannot be delegated to any other entity (for example, a parent corporation). The number of 
individuals who serve on the governing body is determined by the 
organization/individuals who own the clinic or rehabilitation agency. The name of the 
owner(s) or corporate officer(s) (for a corporate entity) is fully disclosed to the State 
Agency. The governing body is expected to meet periodically, consistent with its by-laws. 
 
Contracts: An organization may provide services with direct hire employees (i.e., salaried 
personnel) and with those employees under arrangement (or contract) (485.719). The 
employees hired under contract may provide services wherever the organization provides 
therapy services. 
 
Rehabilitation agencies may contract to provide outpatient therapy services at assisted 
living facilities (ALFs). In this instance, the rehabilitation agency has the administrative 
responsibility and supervisory oversight for the delivery of services in these facilities. In 
addition, the rehabilitation agency is responsible for maintaining clinical records for 
therapy services provided to the ALF patients. 
 
In situations when the OPT is seeing patients in an ALF or ILF, where there is no ongoing 
or permanent presence of the OPT, common areas do not need to be closed off when an 
individual therapy session extends beyond the patients room.  However, OPTs must 
afford patients the opportunity for privacy at the patients request or when clinical 
situations warrant privacy. 
 
Any space leased, rented, or dedicated for the provision of OPT services, including space 
within an ALF or ILF that is designated for therapy service, must meet the two person on 
duty requirement and become a separately certified OPT or become approved as an 
extension location of a currently certified OPT.  Leased or rented space that is dedicated to  therapy services must be closed to non-therapy participants when services are being 
provided. See Section 3100 for additional guidance for situations and when a location 
must be approved as an extension site or separately certified. 
 
2292C - Public Health Agency 
(Rev. 1, 05-21-04) 
 
An official agency established by a State or local government, the primary function of 
which is to maintain the health of the population served by providing environmental health 
services, preventive medical services, and in certain instances, therapeutic services. 
 
2294 - Change of Address 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
When an existing organization intends to move its Medicare approved primary site or a 
rehabilitation agency intends to move any of its approved extension locations to a new 
practice location or the rehabilitation agency desires to add a new practice location , it 
must first notify CMS within 90 days of the expected move and seek approval from the 
RO before it can bill Medicare for covered services from the new address.  Refer to 
424.515 and 424.516  
 
Process: 
 
The organization must submit written notification to the RO regarding its intended 
move 90 days prior to the intended move.  Concurrently, the organization submits 
a modified Form CMS-855A to its Medicare administrative contractor (MAC) or 
fiscal intermediary (FI). 
 
The MAC/FI notifies the RO/SA when it has verified the information. 
 
The RO will evaluate all supporting documentation from the MAC/FI and the 
SA/AO in making its decision to approve or deny the new practice location.  
 
 A survey must be completed in the case of a primary site change of address. 
 
The RO will notify the agency in writing of its decision and provide copies to the 
SA/AO and MAC/FI. 
 
2296  Medicare Approved Sites of Service Provision 
(Rev.83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
A rehabilitation agency must provide services at its approved primary site (the site that 
was issued the CCN).   The organization may apply to CMS for approval of another 
location near the primary site for the purpose of providing additional access to care. These 
locations are known as extension locations and are defined in 42 CFR 485.703. 
 
The mandatory services to be provided at the primary site are physical therapy and/or  speech-language pathology services.  Occupational therapy is an optional service.  The 
extension location must also provide physical therapy and/or speech-language pathology 
services. 
 
The primary site and extension locations must have sufficient equipment and modalities to 
demonstrate that it has an adequate therapy program and can appropriately treat the 
patients that it has accepted for services.  The extension location shares administration, 
supervision, and services with the primary site in a manner that renders it unnecessary for 
the extension location to independently meet the CoPs. 
 
2298  Extension Locations for Rehabilitation Agencies 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
Currently, only rehabilitation agencies are permitted to have extension locations.  The 
clinics operated by physicians and public health clinics are not permitted extension 
locations.  These two providers must provide outpatient therapy services at their Medicare 
approved location. 
 
An extension location is defined at 42 CFR 485.703 as a location or site from which a 
rehabilitation agency provides services within a portion of the total geographic area served 
by the primary site.  The extension location is part of the agency.  The extension location 
should be located sufficiently close to share administration, supervision, and services in a 
manner that renders it unnecessary for the extension location to independently meet the 
conditions of participation as a rehabilitation agency. 
 
This means the extension location and the primary location have the same: 
 
  Governing body, 
 
  Administration; and 
 
  Policies and procedures (e.g., housekeeping, infection control).  However, it is 
important that evacuation plans are specific to the building where the services are 
provided. 
 
The rehabilitation agency may provide a therapeutic service directly at one location while 
providing it under arrangement at another.  A therapeutic service refers to a type of 
professional discipline (i.e., physical therapy, occupational therapy, speech language 
pathology, etc.).  Therapeutic services do not refer to particular types of treatment 
modalities (such as ultrasound or other types of physical agents) applied to produce 
therapeutic changes to biologic tissue. 
 
2298A - Criteria for Extension Location Approval 
(Rev. 150, Issued: 10-30-15, Effective: 10-30-15, Implementation: 10-30-15) 
  It is the CMS RO (not the SA or AO) that has the final authority for approving the request 
for an extension location. The following criteria should be reviewed and assessed in a 
decision regarding the approval or denial of extension locations:  
 
  The extension location must have equipment and modalities appropriate for the 
needs of the patients it accepts for service.  
 
  The administrator and other supervisors at the primary site must be capable of 
adequate supervision of the staff at all extension locations to include management 
and overseeing operations of the extension location.  The administrator may 
delegate aspects of administrative operations at extension locations provided the 
agency has internal policies and procedures ensuring coordinated oversight of all 
locations.  The administrator or his/her designee should be available by telephone, 
at a minimum, and be able to arrive at the extension location in a reasonable 
amount of travel time. 
 
  Primary sites are generally able to meet the requirements for supervision and 
oversight when the extension location being requested is within 30 miles of the 
primary site. Requests for approval of extension locations beyond 30 miles must 
include adequate documentation to support the OPTs ability to maintain 
supervision and oversight of these locations and that the services are being 
provided to a portion of the total geographic area served by the primary site.  An 
example of evidence supporting this would include, but is not limited to, policies 
and procedures describing a structured program for supervision and oversight of 
activities at extension locations.  This may include items such as scheduled 
teleconferences, videoconferencing, and site visits to facilitate administrative and 
personnel management.  Additionally, OPTs may provide a written narrative to the 
CMS RO further describing their supervision and oversight of extension locations.  
The oversight program must ensure that the extension locations maintain 
compliance with all applicable aspects of the CoPs, even though they are not 
required to independently meet all the CoPs as a rehabilitation agency. 
 
  The extension location must provide the same level of privacy and dignity for its 
patients as the primary site does. 
 
  For a rehabilitation agency to establish an extension location across State lines, 
the affected State Survey Agencies must have a signed reciprocal agreement 
allowing approval of the extension location. 
 
2298B - Extension Location Approval Process 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
All extension locations must be approved by CMS before any services are provided and 
billed to Medicare: 
 
  Any proposed extension location, where the rehabilitation agency wishes to 
provide services for its own patients, must be listed on a modified Form CMS- 855A and submitted to the MAC/FI for verification. 
 
  The MAC/FI notifies the RO and/or the SA after it has verified the information 
contained on the Form CMS-855A. 
 
  Concurrently, the rehabilitation agency must submit written notification to the RO 
regarding its intent to open an extension location 90 days prior to opening the new 
location. 
 
  The RO will evaluate all supporting documentation from the MAC/FI and the 
SA/AO in making its decision to approve or deny the new extension location.  
 
  The RO will determine whether a survey needs to be conducted and will instruct 
the SA/AO appropriately. 
 
The RO will notify the rehabilitation agency in writing of its decision to approve or deny 
the extension location and will provide copies of its decision to the SA/AO and MAC/FI.  
The CMS notice letter includes: 
 
  Approval decision for the added practice (extension) location and the date that the 
RO determined the added practice location met all appropriate CoPs, or complete 
reasons for denial if the request was denied:  
 
  The assigned Federal extension location identification number, if approved: 
 
  The identification numbers are not used when submitting claims.  Only 
the NPI is used by the provider to file a claim. 
 
  NOTE:  The RO enters the extension location identification number into 
the Automated Survey Processing Environment (ASPEN) prior to sending 
the notice letter to the agency, so that the rehabilitation agency can begin 
providing services at the new extension location upon receipt of the CMS 
approval letter. 
 
  The effective date: 
 
  The effective date of coverage for services provided from the extension 
location is the date the RO determines that the extension location meets all 
Federal requirements.  This date will be included in the CMS notice letter.  
The organization should not begin providing services at the newly added 
practice location until it receives CMSs notice of its decision to approve or 
deny the new location. 
 
2298C- Survey of Rehabilitation Agency Extension Locations by SAs 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
The surveyor must evaluate each condition and standard in the CoPs at all surveyed  sites.  The surveyor should conduct record reviews, observations and interviews to reach 
conclusions regarding the agencys compliance with the CoPs for care provided at all 
practice locations  before recommending approval by the RO. 
 
The extension location must meet all applicable CoPs.  The approved extension locations 
will not have their own governing body since each location must share administration, 
supervision and services with its primary site. However, if there are concerns with the 
day-to-day operations of the extension location, assess the effectiveness of the governing 
body. Condition  485.713 will be surveyed only if the extension location provides 
physical therapy services.  Condition  485.715 will only be surveyed if speech language 
pathology services are provided.  Condition  485.717 is applicable only to a rehabilitation 
agencys own patients. 
 
The surveyor will record results of interviews and record reviews on the survey report, 
Form CMS-1893 (Outpatient Physical Therapy  Speech Pathology Survey Report), for 
the surveyed locations.  The surveyor completes only one Form CMS-2567(Statement of 
Deficiencies and Plan of Correction) and one Form CMS-1539(Medicare and Medicaid 
Certification and Transmittal) for each agency (primary site and extension locations) 
surveyed. The names of all practice locations (primary and/or extension location) found 
not to be in compliance with each regulation is to be documented on the Form CMS-2567.  
On the CMS-1539, the surveyor notes the names of extension locations in State Agency 
Remarks. Surveys of all locations must be coordinated; therefore, the surveyor should 
schedule and complete surveys of all locations within the same time period.  
 
When the surveyor is certifying compliance, findings at all locations are to be considered 
as a whole. Failure to correct cited deficiencies at any location (extension location or 
primary site) will jeopardize the certification status of the agency in its entirety.  If the 
agency has deficiencies in only some locations, but they are judged significant enough to 
warrant termination, the SA may recommend initiation of termination proceedings to the 
RO. [Refer to SOM Appendix Q or SOM section 3010]. 
 
NOTE:   For a rehabilitation agency to establish an extension location across State lines, 
the two States involved must have a signed reciprocal agreement with each other 
allowing approval of the extension location.  Whether the extension location is in 
the same State as the primary site or in another State, it must conform to all 
regulatory requirements.  An extension location that is situated in a different 
State should bill under the primary sites provider number. 
 
2298D - Accreditation Organization (AO) Surveys of Rehabilitation 
Agencies 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
For organizations seeking certification or recertification through accreditation by an AO 
with an approved program, the AO surveys the primary site and any proposed or existing 
extension locations (of a rehabilitation agency) for compliance with the applicable CoPs. 
After the survey is completed, the AO will recommend to the RO whether a specific 
primary and any extension locations should be approved or denied as practice locations for  the agency. 
 
If the RO approves the addition of practice locations based upon the recommendations of 
the AO, the RO will issue identifiers for those locations and will send a notice letter to the 
rehabilitation agency regarding the RO approval. 
 
The AO may cross state lines to survey an extension location only if there is a reciprocal 
agreement between the two states.  However, the AO should determine whether the 
extension location in the second state is in close enough proximity to the Medicare 
certified primary site to be adequately supervised. 
 
The AO can only survey an extension location and recommend approval to CMS if the 
primary site is already accredited by the AO and has been certified by CMS as a provider 
through deemed status.  If a provider is currently accredited by a CMS-approved AO and 
has been certified by CMS as a provider through deemed status, it may submit a request to 
open an extension location by completing and submitting to the MAC/FI a modified Form 
CMS-855A.  The agency must also notify the AO of its intention to open an extension 
location. 
 
The AO must evaluate each condition and standard in the CoPs at all surveyed sites.   The 
survey should include  record reviews, observations and interviews to reach conclusions 
regarding the agencys compliance with regulations for care provided at all practice 
locations before recommending approval by the RO. 
 
2300 - Outpatient Physical Therapy and/or Speech-Language Pathology 
Services at Other Locations such as a Patients Private Residence, 
Assisted Living or Independent Living Facility 
(Rev. 150, Issued: 10-30-15, Effective: 10-30-15, Implementation: 10-30-15) 
 
In addition to the primary site and any extension locations, the organization may provide 
therapy services in the patients private residence or in a patients room in a SNF/NF, in 
an assisted living facility, or in an independent living facility.  These are services that are 
provided on an intermittent basis where there is no ongoing or permanent presence of the 
OPT.  Examples of an ongoing or permanent presence may be indicated by a dedicated 
therapy gym;  storing of equipment, supplies, or medical records at the facility; or having 
OPT staff regularly assigned to work at that facility directing a coordinated and ongoing 
rehabilitation program at the facility.  These situations are examples that would require the 
OPT to have the other location become separately certified or become approved as an 
extension location. 
 
The agency must provide an adequate therapy program whenever and wherever it provides 
services at locations away from the primary site. The agency must have adequate 
equipment and modalities available, at any location, to treat the patients accepted for 
service. If the agency is providing services at more than one location each day, the agency 
must have infection control policies in place that set forth the techniques the agency 
employees will use at all locations.  
  The agency is responsible for providing any modality that is designated on the plan of care 
or requested by the physician. It is not acceptable for agencies to ask patients to sign 
waivers for modalities that are not available. The agency should refer the patient to 
another agency if needed services are not available at the agency practice location. The 
surveyor should see evidence of the referral in the patients clinical record. 
 
The current plan of care and progress notes must be accessible to service providers anytime 
that the patient is receiving care in order to promote continuity of care. 
 
Periodically, an organization may wish to use a community facility to provide certain 
therapeutic services. For example, the organization may want to use a community pool to 
provide aquatic therapy. The SA or AO shall verify that the community pool meets all 
applicable State laws (i.e., health and safety, infection control requirements, etc.) 
governing the use of the community facility. Also the SA or AO shall review the 
organizations policies and procedures regarding the type of therapy being provided, 
training for staff, supervision, etc. The pool must be closed to public use during the time 
the organization is providing therapy to protect the privacy and safety of the patients being 
treated. The hours of operation and days of the week during which the facility will be used 
for therapy services, supervision, etc. must be clearly stated in the organizations policies 
and procedures as well as the contractual agreement between the community pool and the 
organization. Verify that the organization has a carefully detailed policy regarding specific 
arrangements for emergency services in the event of a medical emergency at the 
community location (i.e., is a telephone in close proximity to the qualified professional 
providing the service, is there a second organization staff person on site, etc. 
 
2302 - CMS -381 Model Letter Requesting Identification of Extension 
Locations 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
Form CMS 381 is no longer required to be collected by the SA on an annual basis as it 
is overly burdensome for the SAs.  The rehabilitation agency must notify both the MAC 
and CMS of its intent to add a new practice location prior to providing physical therapy 
and speech-language pathology services at the new location.  The agency submits its 
request on a modified Form CMS-855A.  The SA should request the agency to submit the 
Form CMS 381, in addition to the modified 855A whenever the agency requests to add 
a new practice location.  The SA must continue to notify the RO when new practice 
locations are added to ensure that identifiers are issued to the new practice locations.  As 
indicated previously, a provider cannot provide services at a new practice location until 
this location has been approved by CMS. 
 
2304 - Operation of an Organization on the Premises of a 
Supplier/Provider 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
There is no prohibition against an organization operating on the premises of a supplier 
(e.g., physician or chiropractor) or another provider as long as they are not operating in the 
same space at the same time.   
At no time can Medicare be billed twice for the same service.  For example, a physician 
and a rehabilitation agency cannot both bill Medicare for therapy services provided by the 
agency for the same patient. 
 
In addition, the supplier must adhere to sections of the Social Security Act that prohibit 
suppliers from referring Medicare patients for certain designated health services (DHS) to 
an entity with which the supplier or a member of the supplier's immediate family has a 
financial relationship, unless an exception applies. 
 
2306  When a Rehabilitation Agencys Extension Location Becomes Its 
Primary Site 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
The rehabilitation agency, following the conversion of its primary site to a CORF, may 
select one of its extension locations as its new primary site.  The SA notifies the RO via 
Form CMS-1539 of the new primary location and any existing, approved, extension 
locations for outpatient physical therapy and/or speech-language pathology services.  A 
new survey must be conducted to certify that the rehabilitation agencys new primary 
location meets the CoPs.  However, any of the rehabilitation agencys other extension 
locations that have already been approved do not require a survey or re-approval as an 
extension location to the new primary site. 
 
2308 - Relocations of Providers of Outpatient Physical Therapy and 
Outpatient Speech-Language Pathology Services Concurrent with 
CHOWs 
(Rev. 83, Issued: 03-15-13, Effective: 03-15-13, Implementation: 03-15-13) 
 
When an agency undergoes a change of ownership (CHOW), the provider agreement is 
automatically assigned to the new owner unless the new owner rejects assignment of the 
agreement.  Automatic assignment of the existing provider agreement to the new owner 
means that the new owner is subject to all the terms and conditions under which the 
existing agreement was issued.  In other words, the new owner must accept all assets and 
liabilities (including, but not limited to, any Medicare payments owed by or due to the 
provider, adhering to existing plans of correction, and maintaining compliance with health 
and safety standards, ownership and financial interest disclosure, and civil rights 
requirements, etc.) of the entity that is being purchased in order to receive the existing 
Medicare Provider Agreement and the CCN.  If the owner accepts assignment, a survey is 
generally not required. 
 
If the new owner does not accept assignment of the provider agreement, the existing 
Medicare Provider Agreement and the CCN will be terminated and the new owner must 
follow the same process as any other prospective provider (i.e., enrolling with the 
MAC/FI, applying for participation, undergoing Office of Civil Rights (OCR) clearance 
and an initial survey, having a new effective date of participation assigned, etc.).  See 
SOM section 3210. 
  A new owner may propose to relocate the organization concurrent with the CHOW.  This 
would be considered as an address change of the existing provider and the new location 
will be surveyed to ensure that it meets all the applicable CoPs.  However, if the relocation 
is to a site that is located in a different geographic area serving different patients than 
previously served and employing different personnel to serve those patients, then the new 
owner must be treated as a new provider in the Medicare program. Refer to SOM section 
3210.1B5 if there are questions regarding this process. 
    Comprehensive Outpatient Rehabilitation Facilities 
(CORFs) 
 
2360 - CORF - Citations and Description 
 
(Rev. 1, 05-21-04) 
 
The statutory basis for CORFs is 1861(cc) of the Social Security Act (the Act).  This was 
amended by 4078 of OBRA 1987 to allow CORFs to provide physical therapy, 
occupational therapy, and speech pathology services off-site.  The CoPs are found in  
42 CFR 485, Subpart B.  Appendix K contains surveyor and interpretive guidelines. 
 
A CORF is a facility established and operated at a single fixed location exclusively for the 
purpose of providing diagnostic, therapeutic, and restorative services to outpatients by or 
under the supervision of a physician (See 2364).  With the exception of financial 
management contracts, the responsibility for overall administration, management, and 
operation must be exercised by the CORF itself and not delegated to others.  Financial 
management contracts may not be for more than five years as governed by 
42 CFR 485.56(f) (formerly 42 CFR 488.56(f)). 
 
2362 - Scope and Site of Services 
 
(Rev. 16, Issued:  10-21-05; Effective/Implementation Date:  11-21-05) 
 
The CORF provides a broad array of services that must include, at a minimum, the 
following three core services:  physician services, physical therapy services and social 
work or psychological services. 
 
With the exception of physical therapy, occupational therapy, and speech-language 
pathology services, all CORF services must be provided on the CORF premises.  
However, one visit to the patients home is allowed to evaluate the home environment in 
relation to the patients established treatment plan.  Physical therapy, occupational 
therapy, and speech pathology services may be provided off the CORF premises 
(including a patients home).  The CORF is responsible for the implementation and 
supervision of any therapy services that are provided at an off-site location.  All 
appropriate CoPs apply to the services provided at off-site locations. 
 
Covered CORF services are those that would be covered as inpatient hospital services if 
furnished in a hospital.  Covered items or services must be reasonable and medically 
necessary for the diagnosis or treatment of an illness or injury or to improve the 
functioning of a malformed body member.  A service furnished as part of a maintenance 
program involving repetitive activities not requiring the skilled services of nurses or 
therapists would not be covered.  A CORF may be reimbursed for optional CORF 
services if they are part of a comprehensive, coordinated, skilled rehabilitation 
program.  (Optional CORF services are:  Occupational therapy, speech-language 
pathology, respiratory therapy, prosthetic and orthotic devices, nursing, drugs and 
biologicals, DME and a single home visit.)   
2364 - CORFS Relationship With Other Providers or Suppliers 
 
(Rev. 1, 05-21-04) 
 
A CORF may be owned by, or affiliated with, a legal entity operating as another type of 
Medicare provider.  The requirement for functional and operational independence does not 
require separate incorporation.  Coordination between such entities in relation to 
personnel, equipment, and facilities is permissible if it is undertaken in accordance with 
2364.  The requirement for functional and operational independence is to assure that any 
entity seeking approval as a CORF meets the requirements for such approval and that the 
costs of different Medicare providers are clearly identified, segregated, and attributed to 
the proper provider. 
 
When certifying a CORF, it is important to understand the relationship of space, 
equipment, and employees shared with other providers and suppliers. 
 
2364A - Shared Space With Another Provider or Supplier 
 
(Rev. 16, Issued:  10-21-05; Effective/Implementation Date:  11-21-05) 
 
A CORF may be established on the premises of another health entity even though the 
other entity is currently approved under Medicare as a provider or supplier of services.  
For example, a SNF owner may rent space within the SNF to the CORF.  The CORF must 
be functionally and operationally independent from the SNF (see 2360). 
 
A CORF may not share a common space with the other entity unless the CORF is able to 
fully function without interruption during its scheduled hours of operation.  Use of the 
CORF space by another, or host entity, during CORF hours of operation is not allowed.  
For example, one room in a suite used by an OPT/OSP provider and owned by the 
OPT/OSP provider or another party may function as a CORF location.  However, although 
the CORF is located on the premises of the OPT/OSP provider, this space is not to be used 
for OPT/OSP purposes during the operating hours of the CORF.  The CORF must make 
provisions to secure medical records from unauthorized use. 
 
2364B - Sharing of Equipment 
 
(Rev. 16, Issued:  10-21-05; Effective/Implementation Date:  11-21-05)    
 
Equipment may be shared in the same manner as space.  All common equipment must be 
available on the premises of the CORF during hours of operation and not used at the same 
time by the other entity for any purpose. 
 
A CORF need not own all of the equipment required for implementing a plan of treatment, 
but it must demonstrate that all required equipment can be readily procured when needed 
and be available in the facility when providing treatment services to the patients. 
  2364C - Employee Sharing 
 
(Rev. 1, 05-21-04) 
 
CORF employees or others may provide CORF services under arrangements with the 
CORF.  It is not required that professional personnel be employed only by the CORF or 
function under arrangements exclusively for the CORF.  However, CORF personnel also 
associated with another organization must be available during CORF operating hours. 
 
2366 - Conversion of OPT/OSP to CORF 
 
(Rev. 1, 05-21-04) 
 
An OPT/OSP primary location may convert to a CORF if it meets the CORF CoPs.  
Normally, the OPT/OSP provider will relinquish its OPT/OSP site unless it shares space 
with the CORF.  To share space, an identifiable part of the OPT/OSP at the site must be 
set aside exclusively for the operation of the CORF and treatment of CORF patients 
during CORF hours of operation. 
    Suppliers of Portable X-Ray Services 
 
2420 - Suppliers of Portable X-Ray Services - Citations 
 
(Rev. 1, 05-21-04) 
 
The statutory authority for coverage of suppliers of portable x-ray services is found in 
1861(s)(3) of the Act.  The regulations are found in 42 CFR 486, Subparts A-C.  
Appendix D contains surveyor and interpretive guidelines. 
 
2422 - Location of Portable X-Ray Service 
 
(Rev. 1, 05-21-04) 
 
Diagnostic x-ray tests (including tests furnished in a place of residence used as the 
patients home) must be under the supervision of a physician.  The residence used as the 
patients home can include a SNF or hospital that does not provide x-ray services for its 
patients and arranges for these services through a portable x-ray supplier, such as a mobile 
unit.  However, to be certified as a portable x-ray supplier, the mobile unit can neither be 
fixed at any one location nor permanently located in a SNF or a hospital. 
 
Despite the mobility of the services, the base office address of the supplier must be 
identified as the supplier, and the supplier must be approved in each State in which its 
operation is based.  A post office box number does not suffice. 
 
Portable x-ray suppliers operating across state lines may or may not maintain separate 
offices in multiple states.  Those that operate in states other than where they are based 
must meet State and local laws of each state in which they operate.  The certifying SA in 
such instances must check whether the other State permits such operation by reciprocal 
State agreements.  Note on the survey report whether the other State has such a 
requirement, and if so, whether the specific supplier is permitted to operate in the other 
State. 
 
2424 - Suppliers Using Improperly Labeled or Post-1974 Equipment 
 
(Rev. 1, 05-21-04) 
 
2424A - Labeling Requirements 
 
(Rev. 1, 05-21-04) 
 
Condition 42 CFR Part 486.100 requires portable x-ray suppliers to provide their services 
in conformity with Federal, State, and local laws.  This includes the requirement that the 
facilities comply with Food and Drug Administration (FDA) performance standards for 
diagnostic x-ray systems at 21 CFR Subchapter J, Radiological Health.  These standards 
first became effective August l, 1974, and have been amended several times since.   Diagnostic x-ray systems covered by these standards (manufactured August 1, 1974, or 
later) must bear a label or tag indicating that the equipment met the FDA standards at the 
time of installation in a facility.  Systems manufactured before August 1, 1974, are exempt 
from the standards.  However, if new components manufactured after August 1, 1974, are 
installed in systems manufactured before that date, the new components must meet the 
standards and be properly labeled.  Equipment that does not bear such a label may be 
either pre-1974 manufactured equipment, which is legal to use without a label, or post-
1974 equipment from which the label was removed and which should not be used by the 
portable x-ray supplier. 
 
2424B - Request for and Review of Labeling Information 
 
(Rev. 1, 05-21-04) 
 
In order to facilitate the process of determining whether portable x-ray equipment meets 
FDA standards, the SA must request the supplier to submit the following information on 
all unlabeled equipment prior to the survey or resurvey: 
 
  Name of manufacturer; 
 
  Equipment model number; 
 
  Equipment serial number; and 
 
  Date of manufacture (if available). 
 
The SA checks the information with the State radiation health specialists who perform the 
equipment surveys.  If doubt exists as to whether the equipment used by a particular x-ray 
supplier meets Federal standards, the SA forwards the case to the RO for HSQB 
verification with the FDA.  The SA must not certify or recertify the supplier of portable x-
ray services until questions concerning the equipments legality are resolved. 
  Screening Mammography 
 
2460 - Mammography  
 
(Rev. 1, 05-21-04) 
 
The Mammography Quality Standards Act of 1992 (354 of the Public Health Services 
Act) requires all facilities providing diagnostic and screening mammography services to 
have a certificate issued by the Food and Drug Administration (FDA), regardless of their 
source of reimbursement. Therefore, all mammography suppliers participating in the 
Medicare program must have a certificate issued by the FDA and do not undergo a 
Medicare survey.  The CMS ROs do not assign a supplier number to mammography 
suppliers participating in the Medicare program and collect no health and safety data 
concerning them.  Medicare payments are made to mammography suppliers based on the 
FDA certificate number.  (Also see 1861(jj) and 1834 of the Act.) 
  Life Safety Code (LSC) 
 
2470 - LSC - Citations and Applicability  
 
(Rev. 1, 05-21-04) 
 
(Also see Chapter 7, 7410) 
 
2470A - Background 
 
(Rev. 1, 05-21-04) 
 
The LSC is a set of fire protection requirements designed to provide a reasonable degree 
of safety from fire.  It covers construction, protection, and operational features designed to 
provide safety from fire, smoke, and panic.  The LSC, which is revised periodically, is a 
publication of NFPA, which was founded in 1896 to promote the science and improve the 
methods of fire protection. 
 
The basic requirement for facilities participating in the Medicare and Medicaid programs 
is compliance with the 2000 edition of the LSC.  Facilities with waivers of the health 
occupancy provisions of the LSC or with an acceptable PoC are considered in 
compliance. 
 
2470B - Citations for Application to Provider Facilities 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The LSC is applied to hospitals under authority of 1861(e)(9) of the Act and by 
42 CFR 482.41(b).  SNFs and NFs must meet 42 CFR 483.70(a) that implements 
1819(d) and 1919(d) of the Act.  The LSC is applied to ICFs/IID under the authority of 
1905(d) of the Act and 42 CFR 483.470(j).  It is applied to hospices furnishing inpatient 
care pursuant to 42 CFR 418.100(d) and to (ASCs) under 42 CFR 416.44(b). It is applied 
to Religious Nonmedical Health Care Institutions (RNHCI) under 42 CFR 403.744 and to 
Programs of All-Inclusive Care for the Elderly (PACE) under 42 CFR 460.72. (See 
Appendix I for interpretive guidelines.) 
 
2470C - Citations for Application to ASCs 
(Rev. 1, 05-21-04) 
 
ASCs wishing to participate in the Medicare program must comply with the 2000 edition 
of the LSC, as it applies to ambulatory health care centers regardless of size.  The 
requirements for ASCs are contained in Chapter 20 for new facilities, and in Chapter 21 
for existing facilities.  ASCs must comply with Chapter 38 and Chapter 39 (Business 
Occupancies) in certain instances, such as where high-rise buildings must be sprinklered if 
they contain ASCs. 
 
2470D - Special Application in ICFs/MR  (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
All ICFs/IID must meet the 2000 edition of the LSC. 
 
2470E - Substitution of State Fire Code for the Life Safety Code (LSC) 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The LSC is not applicable where CMS finds that a State has in effect a fire and safety 
code imposed by State law that adequately protects patients in health care facilities, except 
for small ICFs/IID surveyed under the Residential Board and Care Chapters (Chapters 32 
and 33).  (See 1863 of the Act.)  
 
The State submits a request that State codes be utilized in lieu of the LSC to the CMS/RO.  
That office will forward the request to central office (CO) for a determination.  Include a 
copy of the enabling legislation so that the CO can determine whether the applicable State 
law adequately protects patients in healthcare facilities. 
 
Upon notification by CO, the RO advises the State authority that submitted the request 
whether the State code is acceptable in lieu of the LSC.  State codes cannot be submitted 
for ICFs/IID since CMS has no authority to accept them in lieu of the LSC. 
 
2472  Life Safety Code (LSC) Surveys 
(Rev. 1, 05-21-04) 
 
2472A - Authority to Grant Waivers for LSC Surveys 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The LSC provides that the authority having jurisdiction shall determine the adequacy of 
protection provided for life safety from fire in accordance with the provisions of the LSC.  
In cases of unreasonable hardship, 42 CFR 483.70(a)(2) specifies that a waiver may be 
granted where it would not adversely affect resident health and safety. 
The Secretary has delegated to CMS the authority to grant waivers of LSC provisions for 
all facilities participating in Medicare and Medicaid with the exception of ICFs/IID.  The 
State LSC surveyor recommends waivers, but CMS ROs grant the waivers.  Therefore, 
LSC requests the SA receive from all providers except ICF/IIDs must be forwarded to the 
RO for adjudication.  For ICFs/IID, the State has the authority to grant waivers of health 
care occupancy requirements.  There is no authority for either the State or the RO to grant 
waivers of Board and Care Occupancy provisions. 
 
2472B - Subagreements With State Fire Authorities 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
To assess facilities compliance with the LSC and other Medicare and Medicaid fire safety 
requirements, the SA may enter into a subagreement or a contract with the State fire 
Marshals office or other State agency responsible for enforcing State fire code 
requirements. Under this agreement, the designated State fire authority generally agrees 
to:   
  Survey all non-accredited hospitals, hospices, ASCs, SNFs, NFs, CAHs, RNHCIs, 
PACE Facilities and ICFs/IID in accordance with schedules you furnished; 
 
  Survey accredited hospitals selected for validation surveys or surveyed as a result 
of a substantial allegation of an unsafe conditions; 
 
  Complete the appropriate Fire Safety Survey Report (Form CMS-2786);  
 
  Prepare statements of deficiencies and review PoCs (Form CMS-2567); 
 
  Make recommendations to you regarding facilities compliance with program fire 
safety requirements; and 
 
  Use only qualified fire safety inspectors in the performance of these surveys. 
 
2472C - Coordinating LSC Survey 
(Rev. 1, 05-21-04) 
 
In most cases, the SA schedules the LSC survey to coincide with the health survey; 
however, the timing of the LSC is left to the discretion of the SAs.  The SA determines 
whether the LSC survey is to occur before, after, or simultaneously with the health survey.  
If the health survey and the LSC survey are conducted at different times, data entry into 
OSCAR must be deferred until both surveys are completed, and the data of the latest 
segment of the total survey (the health portion or the LSC portion) is used for OSCAR 
purposes.  In order to complete data submissions in a timely manner, input of the life 
safety code survey data of long term care facilities should take place not later than 60 days 
after the conclusion of the long term care survey.  Most States require an initial LSC 
survey before admitting patients prior to becoming operational.  Regardless of the timing 
of the LSC survey, the SA should schedule it so that all certification actions are completed 
timely. 
 
2472D - ASC Surveys 
(Rev. 1, 05-21-04) 
 
The SA uses Form CMS-2786U to survey ASCs.  The SA lists any LSC deficiencies 
found during an ASC survey on Form CMS-2567 and requests a PoC as with any LSC 
survey of a health care facility. 
 
2472E - Involvement of SA Surveyors in LSC Surveys 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
A full-scale LSC survey need not be performed every year if building characteristics have 
not changed.  As long as the fire authority surveys every third year and the institution 
remains in compliance, the SA surveyors can complete a Fire Safety Survey Report - 
Short Form (CMS-2786S) as part of the recertification survey in the intervening years.  
(See 2476.)   
In surveys of ICFs/IID, fire authorities decide, in accordance with guidelines in Appendix 
I, which chapters of the LSC pertain in each instance and survey accordingly.  However, 
the fire authority is not professionally trained to observe resident behavior and relies on 
information furnished by staff members to rate the level of mobility and self-preservation 
of residents.  Consequently, when the SA surveys an ICF/IID, it takes a copy of the 
Worksheet for Rating Residents (F-1, Side 2, Form CMS-2786M) for each resident that 
the fire authority completed, and takes a blank copy of the same worksheet.  Complete 
Items I through VI of the Worksheet to corroborate the information used by the fire 
authority.  The SA reconciles any discrepancies with the fire authority before certifying 
the facility. 
 
Fire authorities are also advised in Appendix I to alert the SA to situations involving 
institutions not in compliance which present immediate jeopardy to residents so that the 
SA can initiate timely termination development without waiting for the written 
documentation of the LSC survey. 
 
2474 - Fire Safety Survey Report Forms (Form CMS-2786 Series) 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The Form CMS-2786 series contains the forms to be used for determining compliance 
with the LSC.  There are currently 13 in this series: 
 
1.  Form CMS-2786M, Fire Safety Survey Rating Residents; 2000Code. 
   
2.  Form CMS-2786R, Fire Safety Survey Report 2000 Code-Health Care - 
Medicare/Medicaid. 
   
3.  Form CMS-2786S, Fire Safety Survey Report - Short Form; 2000 Code. 
   
  Form CMS-2786T, Fire/Smoke Zone Evaluation Worksheet For Health 
Facilities; 2000 Code. 
   
  Form CMS-2786U, Fire Safety Survey Report Ambulatory Surgical Centers; 
2000 Code.  
   
  Form CMS-2786V, Fire Safety Survey Report ICF/IID -Small Facilities; 
2000Code. 
   
  Form CMS-2786W, Fire Safety Survey Report ICF/IID-Large Facilities; 2000 
Code. 
   
  Form CMS-2786X, Fire Safety Survey Report ICF/IID Apartment House; 2000 
Code. 
   
4.  Form CMS-2786Y, Fire Safety Survey Report ICF/IID- Small FSES; 2000 Code. 
  They each contain four parts: 
 
  I.  LSC requirements - New and Existing; 
 
 II.  Other Federal requirements; and 
 
III.  Waiver recommendation form. 
 
2476 - Fire Safety Survey Report - Short Form, Form CMS-2786S 
(Rev. 1, 05-21-04) 
 
2476A - Background 
(Rev. 1, 05-21-04) 
 
The Fire Safety Survey Report - Short Form (Form CMS-2786C), (see Exhibit 71), was 
designed as a screening tool for LSC compliance, since it may not be necessary to conduct 
a complete survey of all facilities annually.  Some features of a building do not change 
from year to year, e.g., an 8-foot corridor remains eight feet wide.  Other items require 
periodic testing and maintenance, e.g., sprinkler systems and fire extinguishers.  Such 
testing is easily verified by a check of service records.  Verification does not require the 
level of expertise of a fire protection engineer or fire marshal, and can be capably 
performed by the SA surveyor. 
 
2476B - When to Use Short Form 
(Rev. 1, 05-21-04) 
 
Except as outlined in subsection C, the SA uses Form CMS-2786S to survey non-JCAHO 
hospitals, SNFs, and NFs for compliance with the LSC. 
 
2476C - When NOT to Use Short Form 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Instead of the SA using the short form in the following situations, the SA should have the 
State fire authority perform the survey using the regular Fire Safety Survey Report (Form 
CMS-2786R*): 
 
  Initial survey; 
 
  Survey of facilities with any construction or renovation since their last survey 
(facilities must report any construction or renovation to you); 
 
  Facilities with uncompleted PoCs (including facilities with waivers to complete 
construction activities; 
 
  ICFs/IID; 
 
  ASCs;    
  Surveys preceded by two successive certification surveys in which the Short Form 
was used; or 
  When conducting the first LSC survey under the 2000 Edition of the LSC. 
 
2476D - Results of LSC Screening Process - SA Review of Completed 
Form CMS-2786S 
(Rev. 1, 05-21-04) 
 
1 -  All Items Met - No deficiencies. 
 
2 -  Some Items Not Met - If any item is not met the SA forwards the form to the 
State fire authority who will determine whether a complete survey is necessary. 
 
3 -  Complete Survey Recommended - The SA checks this block if there are 
many deficiencies or if it finds recent construction or renovation.  The SA 
forwards the form to the State fire authority who takes appropriate action. 
 
4 -  Submission of Completed Package - When the Short Form is completed, the 
SA forwards it to the RO as part of the complete certification kit.  (Note that 
OSCAR includes a special field on the crucial data extract (CDE) sheet for use 
of the Short Form.) 
 
2476F - Waivers 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Items that have been waived in the past can continue to be waived even if a Short Form 
is used.  If the health surveyor marks an item not met and the provider requests a waiver, 
the SA should have the waiver reviewed by the fire authority.  The fire authority must 
decide whether to recommend waivers in the case of SNFs, NFs, or ICFs/IID, however, 
CMS must grant the waiver, not the State.  There are no waivers for ICFs/IID under the 
Board and Care provisions.  In no case is the health surveyor to recommend, grant, or 
review a waiver. 
 
2478 - Application of Fire Safety Evaluation System (FSES) 
(Rev. 1, 05-21-04) 
 
2478A - General 
(Rev. 1, 05-21-04) 
 
The National Bureau of Standards developed the FSES at the request of DHHS.  It is an 
alternative method of determining compliance with the provisions of the LSC.  Facilities 
that pass the FSES may be certified for participation in the program even though they have 
repeated deficiencies reflected on Form CMS-2786. 
 
2478B - Application of System  (Rev. 1, 05-21-04) 
 
The State fire authority uses the FSES in conjunction with Form CMS-2786 in facilities 
where the surveyor or the provider feels that the application of the system is beneficial to 
the facility.  The state may complete the FSES for the facility at the States option.  The 
State Fire Authority will review and approve any FSESs submitted by the provider. 
 
2478C - Survey Completion  
(Rev. 1, 05-21-04) 
 
Whenever an FSES evaluation is conducted by the fire authority, the following is 
completed: 
 
  Fire Safety Survey Report (Form CMS-2786); 
 
  FSES zone evaluation worksheet for each fire/smoke zone evaluated; 
 
  Copy of FSES table 8 (facility fire safety requirements worksheet); and 
 
  Statement of deficiencies (Form CMS-2567) for LSC and FSES items. 
 
The SA includes all FSES worksheets with the certification kit, even if certification is 
based on the findings of Form CMS-2786. The SA marks item 7A of the cover sheet of 
Form CMS-2786 FSES.  FSES files are forwarded by the RO to a specialist for a 
thorough technical review. 
 
2478D - Certification of Compliance with FSES 
(Rev. 1, 05-21-04) 
 
When the fire authority performs an FSES evaluation, a facility may elect to be certified 
with deficiencies as well as an acceptable PoC in either of two ways: 
 
  If the provider elects to be certified based upon the findings of the Form 
CMS-2786, it must indicate its proposed correction in the space adjacent to each 
deficiency recorded on Form CMS-2567; or 
 
  If the provider elects to be certified based on the FSES, it may not be necessary to 
correct all of the deficiencies found.  In this case, the provider is to write: Not 
Necessary to Correct - FSES in the space next to such deficiencies under Plan of 
Correction.  A facility that achieves a passing score on the FSES or which 
submits an acceptable PoC under the FSES may be certified based upon the FSES.  
Once a facility has been certified based upon the FSES, it may continue to be 
certified on that basis in subsequent certification surveys after completion of the 
Form CMS-2786. 
 
The SA refers any questions regarding application of the FSES, completion of the zone 
evaluation worksheet, appropriate documentation of PoCs, or requests for technical  assistance to the LSC contact person in the RO. 
 
2480 - LSC Waivers 
(Rev. 1, 05-21-04) 
 
2480A - General 
(Rev. 1, 05-21-04) 
 
In some cases, certain provisions of the LSC might not be met, although the facility 
provides a reasonable degree of fire safety.  Exceptions to the LSC are permissible if: 
 
  The waiver would not adversely affect patient health and safety; and 
 
  It would impose an unreasonable hardship on the facility to meet specific LSC 
provisions. 
 
Although compliance with the LSC would generally be easier for a new facility than for 
an existing building, there may be an occasional situation that would justify the granting 
of a waiver in new construction.  For example, in the course of drawing up building plans, 
an architect will often discuss prospective design features with State Building Department 
officials and licensure authorities.  It is not unusual for these authorities to grant approval 
for innovative design features that, while not in strict conformity with the LSC, 
nevertheless provide an equivalent degree of protection.  In such circumstances, a waiver 
may be appropriate. 
 
When it is not readily practical for an institution to comply fully with all the individual 
requirements of the LSC, the fire authority evaluates the degree of enforcement necessary 
to provide a reasonable measure of safety.  In making this recommendation, it considers 
whether the intent of the LSC is met. 
 
2480B - Meeting Intent of LSC 
(Rev. 1, 05-21-04) 
 
The requirements of the LSC are directed to a series of factors or areas.  These may be 
classified as follows: 
 
1.  Fire Load - All materials which might contribute to the fuel aspect of a fire within 
the building and requirements pertaining to construction, interior finish, draperies, 
furnishings, and building service equipment; 
 
2.  Fire Containment - Those elements which tend to restrict the spread of flame, 
smoke, or fire gases throughout the building, such as corridor wall construction, 
subdivision of floor areas, and protection for vertical openings; 
 
3.  Fire Extinguishment - Elements which help to put out the fire as quickly as 
possible.  They include alarm systems, portable extinguishers, sprinkler systems, 
and special requirements for protection of hazardous areas;   
4.  Evacuation - Those elements which facilitate the removal of occupants from the 
scene of the fire.  They include details of the emergency plan and exiting capability 
from the building; 
 
5.  Operating Features - The administrative and operational features such as 
housekeeping techniques, smoking regulations, and the fire emergency plan which, 
if not properly implemented, could result in hazardous fire situations; 
 
The following additional considerations should also be evaluated by the fire authority 
since they may have an important bearing on the safety of patients in facilities which 
request a waiver: 
 
1.  Staffing considerations such as staff-patient ratios, staffing patterns, and scope of 
staff training to handle fire emergencies; 
 
2.  Availability and adequacy of compartment and horizontal exits, such as areas to 
hold patients during a fire emergency; 
 
3.  Location and number of ambulatory and nonambulatory patients; 
 
4.  Availability, extent, and type of automatic fire detection and fire extinguishment 
systems provided in the facility; 
 
5.  Means for notifying the fire department in case of fire; and 
 
6.  Effectiveness of fire department (e.g. types of equipment available, number of 
personnel normally responding to a fire call, distance to the nearest fire station, and 
normal response time of the fire department). 
 
The total fire safety of a building is dependent upon the combined effect of the factors 
mentioned above.  Each building is a unique problem from a fire safety point of view and 
should be evaluated by the fire authority on its own merits.  Not all requirements are of 
equal importance in all situations. 
 
If it can be established that a particular deficiency does not materially affect the overall 
level of safety, it is reasonable to hold that the fire safety characteristics of the facility 
have not been compromised and that the intent of the LSC has been met. 
 
2480C - Elements Considered in Determination of Unreasonable 
Hardship 
(Rev. 1, 05-21-04) 
 
In cases in which patient safety would not be adversely affected by a waiver, consider the 
following factors in evaluating the issue of unreasonable hardship: 
 
  Estimated cost of the installation;   
  Extent and duration of the disruption of normal use of patient areas resulting from 
construction work; 
 
  Estimated period over which cost would be recovered through reduced insurance 
premiums and increased payment related to cost; 
 
  Availability of financing; and 
 
  Remaining useful life of the building. 
 
2482 -Technical Bulletins 
(Rev. 1, 05-21-04) 
 
A - Technical Codes And Standards Committee Charter and Function 
 
The Technical Codes and Standards Committee was abolished in 1987 because the 
majority of the bulletins were written prior to publication of the 1981 edition of the LSC 
and are no longer applicable. 
 
2490 - Compliance With 504 of the Rehabilitation Act of 1973, as 
Amended 
(Rev. 1, 05-21-04) 
 
The American National Standards Institute specifications have been superseded by the 
HHS Departmental 504 regulations.  Enforcement of 504 of the Rehabilitation Act of 
1973, as amended by the Rehabilitation Act of 1974, in Federally assisted programs or 
activities includes a cross-reference to the Uniform Federal Accessibility Standards 
(UFAS).  (See 45 CFR Part 84.)  Because some facilities subject to new construction or 
alteration requirements under 504 are subject to the Architectural Barriers Act, 
government-wide reference to UFAS diminishes the possibility that recipients of Federal 
financial assistance will face conflicting enforcement standards.  The surveyor has the 
responsibility to report any suspected noncompliance with 42 CFR Part 504 to the RO via 
Form CMS-1539.  The RO will refer the matter to Office of Civil Rights (OCR) for 
resolution. 
  Utilization Review 
 
2496 - Utilization Review (UR) 
(Rev. 1, 05-21-04) 
 
2496A - Definition 
(Rev. 1, 05-21-04) 
 
Utilization Review is the process by which the care and services provided to Medicare and 
Medicaid beneficiaries are reviewed for appropriateness, medical necessity, and whether 
the services meet professionally recognized standards of health care. 
 
2496B - Hospitals 
(Rev. 1, 05-21-04) 
 
Utilization Review requirements for Medicare and Medicaid hospitals are contained in 
1861(k) of the Act.  The Medicare UR regulations for hospitals are contained in 42 CFR 
482.30, CoPs - Utilization Review. 
 
Under Medicare, the Quality Improvement Organization (QIO) performs the UR function 
for hospitals.  42 CFR 466.78 requires that beginning November 15, 1984, every hospital 
seeking payment for services provided to Medicare beneficiaries maintain a written 
agreement with a QIO operating in the area in which the hospital is located. 
 
The law and regulations require that a hospital maintain an agreement with the QIO for the 
QIO to review the admissions, quality, appropriateness, and diagnostic information related 
to inpatient services for Medicare patients, if there is a QIO with a contract with CMS in 
the area where the hospital is located.  Also, regulations at 42 CFR 476.86 permit the QIO 
review activities to fulfill the hospitals UR requirements.  State survey agencies acting on 
behalf of CMS are not required to review the UR CoP.  QIOs are to review hospital 
admissions (paid under the Medicare prospective payment system) under the program 
referred to as the Payment Error Prevention Program (PEPP) for Medicare.  The purpose 
of PEPP is to reduce the occurrence of errors that may result in incorrect payment to 
hospitals.  (The regulations also refer to other, non-hospital groups that could perform UR 
functions when the QIO does not fulfill this function or if DMS has favored a states 
procedures). 
 
The UR requirements under Medicaid are largely determined by those under Medicare.  
Section 1903(i)(4) of the Act provides that Federal financial participation is not available 
in a states expenditures for hospital services unless the institution has in effect a UR plan 
that meets Medicare requirements.  Under the law, if a hospital already has a UR plan in 
effect for Medicare, that plan serves as the plan required by Medicaid, with the same 
procedures and the same review committee or group.  Therefore, if there is a UR plan that 
does not include a hospital-based UR committee for Medicare, none should be used for 
Medicaid. 
 
If a facility does not participate in Medicare, it must meet the Medicaid regulatory  requirements, which 42 CFR 456.501(c) describes as equivalent to the Medicare 
regulatory UR requirements (with possible alternatives to hospital committee review).  In 
addition, 42 CFR 456.505 of the regulations provides that the Administrator may waive 
the standard UR plan requirements if the state Medicaid agency applies for a waiver, and 
demonstrates that it has specific UR procedures in operation that are superior in their 
effectiveness to those in the Medicaid regulations. 
 
2496C - SMAs 
(Rev. 1, 05-21-04) 
 
Section 1902(d) of the Act allows SMAs the option of contracting with a QIO to perform 
UR functions.  A State may be deemed to meet the State plan requirements specified in  
42 CFR 456, Subparts C and D, for those services or providers reviewed by such 
organization under such a contract. 
 
2496D - Background and Scope of Work 
(Rev. 1, 05-21-04) 
 
The QIOs were established under the provisions of P.L. 97-248, the Tax Equity and Fiscal 
Responsibility Act of 1982.  The law requires the Secretary to enter into contracts with 
physician-sponsored or physician-access organizations to review services provided to 
Medicare beneficiaries to insure that the care they receive is medically necessary, 
appropriate, and of a quality that meets professionally recognized standards of care.  The 
ultimate goal of the QIO is to improve the quality of care provided to Medicare 
beneficiaries by utilizing statistical quality control measures to examine variations in both 
the processes and the outcomes of care. 
 
2496D1 - Extent of PRO Review 
(Rev. 1, 05-21-04) 
 
To participate in the Medicare program, every hospital must have an agreement with a 
QIO to perform utilization and quality review in that institution.  Effective October 1, 
1987, SNFs, HHAs, and hospital outpatient departments (HOPDs) must have an 
agreement with a QIO.  This agreement allows QIOs to review post-hospital care, such as 
care provided in a SNF or by an HHA which is given between a hospital admission and 
readmission occurring within 31 calendar days of discharge. The QIO then responds to 
beneficiary complaints about the quality of care given by SNFs, HHAs, and hospitals 
(including HOPDs).  QIOs also have agreements with ASCs to review a sample of 
Medicare surgical records for medical necessity.  For hospitals certified as swing-bed 
providers, the QIO reviews a sample of cases to determine the medical necessity of the 
stay and the appropriateness of the setting. 
 
42 CFR 488.14 indicates that when a QIO conducts review activities under 1154 of the 
Act and 42 CFR 466, its activities shall be in lieu of the UR and evaluation activities 
required of health care institutions under 1861(e)(6) and 1861(k) of the Act.  In 
addition, any QIO review activity will also be in lieu of survey, compliance, and 
assistance activities required of SAs under 1864(a) of the Act.   
2496D2 - Availability/Disclosure of QIO Information 
(Rev. 1, 05-21-04) 
 
As a result of their review activities, PROs have information related to practitioners and 
institutions that may be helpful to the SA.  42 CFR 476.138(a)(1) provides for disclosure 
of this information to licensing and certification bodies if it is required by the agency to 
carry out a function within the jurisdiction of the agency under Federal or State law.  A 
QIO must disclose confidential information upon request, or may do so without a request, 
to a State or Federal body responsible for professional licensure of a practitioner or an 
institution.  
 
Information about an institution that does not identify individuals is not confidential 
information and may be disclosed.  However, 42 CFR 476.105(b)(2) requires disclosure to 
conform with notice of disclosure requirements.  In general, a QIO must notify a 
practitioner or institution of its intent to disclose information to a licensing or certification 
body and provide the practitioner or institution with a copy of the information it will 
disclose at least 30 calendar days in advance. 
 
When disclosing the information, the QIO includes any comments submitted by the 
practitioner or institution if they were received prior to disclosure, or forwards comments 
separately if received after disclosure.  Recipients of confidential QIO information are 
prohibited from disclosing the information unless specifically provided for in Federal 
regulation.  For example, in accordance with 42 CFR 476.107(e), if the QIO acquires 
information from a hospital and provides the information to a licensing body that is 
authorized to acquire the information directly from the hospital, the licensing body may 
then disclose the information in accordance with the hospitals redisclosure rules. 
 
The SA should work with QIOs to identify and obtain information that will be helpful to it 
in the survey and certification process.  If further information or assistance is needed, 
including name and address of the area QIO, the SA contacts the RO. 
 
2496E - Action When a QIO Ceases Utilization Review 
(Rev. 1, 05-21-04) 
 
The SA instructs hospitals and SNFs to forward a copy of their UR plan to it within 90 
days of a QIOs cessation of review activity in that area.  If the plan does not meet the 
requirements, the SA returns it for necessary revisions. 
 
2496F - Including UR in Next Scheduled Resurvey 
(Rev. 1, 05-21-04) 
 
The SA conducts a brief review of UR activities during the next regularly scheduled 
survey of the institution to verify that the UR plan is in place and functioning.  For 
accredited hospitals where surveys are not regularly performed, the SA instructs the 
hospitals to send it copies of the minutes of their UR committees meetings (or a summary 
or synopsis of the minutes).  The SA reviews the current UR plan against the regulations  themselves (there is no UR Survey Report at the present time) to verify that the plan meets 
the applicable requirements and reviews the institutions conduct of UR activities against 
that written plan. 
 
The SA records any UR deficiencies and plans of correction; after all other deficiencies 
have been recorded on the Form CMS-2567.  (These deficiencies will not be recorded in 
MMACS.) 
 
The SA records the status of the institutions UR compliance in the Remarks portion of 
the Certification and Transmittal, Form CMS-1539, e.g., name of facility is in compliance 
with UR requirements, or Acceptable Plan of Correction for UR has been submitted.  The Survey Process 
 
(See Chapter 7 for SNFs and NFs) 
 
2700 - Conducting Initial Surveys and Scheduled Resurveys 
(Rev. 1, 05-21-04) 
 
2700A - Unannounced Surveys 
(Rev. 1, 05-21-04) 
 
It is CMS policy to have unannounced surveys for all providers (including all types of 
hospitals) and suppliers (other than laboratories).  Sections 1819(g)(2)(A)(I), 
1919(g)(2)(A)(I), and 1891(c)(1) of the Act establish civil money penalties (CMPs) for 
any individual who notifies a SNF, NF, or HHA of a survey.  (See 2008 and 7207.) 
 
While the unannounced surveys may result in some minor inconveniences, this policy 
represents changing public attitudes and expectations toward compliance surveys.  If there 
is any conflict with internal State policies and practices, the SA should discuss the 
problem with its RO.  To enhance the unpredictability of unannounced standard surveys of 
LTC facilities, special selection criteria are to be incorporated when State agencies are 
scheduling standard surveys to LTC facilities.  (See 7207.) 
 
Exception: Non-LTC facilities other than HHAs may be given advance notice (usually no 
more than one working day before an impending survey) if all of the following criteria are 
met: 
 
  The facility is inaccessible via conventional travel means and it is necessary to make 
special or extraordinary travel arrangements; and 
 
  There is a high probability that the staff essential to the survey process will be absent, 
or the facility will be closed unless the survey is announced.  (See 2008.) 
 
  The announced survey is approved by the RO on a case-by-case basis. 
 
2700B - SA Schedule for Conducting Health and Safety Resurveys 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The SA resurveys and recertifies providers/suppliers on a cyclical basis in accordance 
with the survey coverage levels specified in the budget call letter.  Surveys of SNFs, NFs, 
and HHAs must be on a flexible cycle in order to reduce the predictability of the survey.  
(See 2008.D.)  SNFs and NFs must be subject to a standard survey no later than 15 
months after the previous survey and HHAs must be subject to a standard survey within a 
36-month interval.  The SA surveys ICFs/IID no later than 15 months after the previous 
survey so that a timely certification can be ensured.  The SA should consider geographical 
considerations and the scheduling of licensure visits so that coordinated visits can be made 
whenever possible.  Change of Ownership (CHOWs) or other changes that may affect a 
providers/suppliers compliance status may necessitate adjustment of the SA survey  interval.  (See 2702.) 
 
2700C - Coordinating LSC Surveys 
(Rev. 1, 05-21-04) 
 
In most cases, the SA schedules the LSC survey to coincide with the Health survey.  
However the timing of the LSC survey is left to the discretion of the SAs.  The SA 
determines whether the LSC survey is to occur before, after, or simultaneously with the 
health survey.  If the health survey and the LSC survey are conducted at different times, 
data entry into OSCAR must be deferred until both surveys are completed, and the data of 
the latest segment of the total survey (the health portion or the LSC portion) is used for 
OSCAR purposes.  Most States require an initial LSC survey before allowing a 
provider/supplier to admit patients prior to becoming operational.  Regardless of the 
timing of the LSC survey, the SA should schedule it so that all survey and certification 
actions are completed timely. 
 
2702 - SA Conducting Unscheduled Surveys 
(Rev. 1, 05-21-04) 
 
2702A - Survey Due to Unanticipated Events 
(Rev. 1, 05-21-04) 
 
It may be necessary to conduct a complete survey at an earlier date than planned.  Possible 
reasons for this include: 
 
  A complaint about deteriorating standards of care; 
 
  Results of a complaint validation survey of an accredited hospital/find CoP out of 
compliance;  
 
  Loss of hospital accreditation; 
 
  An employee strike; 
 
  Change of ownership or changes in managerial personnel; or  
 
  A significant change in the type of treatment provided. 
 
The decision to conduct a full survey at an earlier date than originally planned depends 
upon whether there is a likelihood that the certification (or compliance) status could have 
changed.  Do not announce such surveys.  The SA should schedule subsequent surveys 
based upon the date of this survey.  (See 7205 for SNF/NF.) 
 
2702B - Change of Size or Location of Provider Institution 
(Rev. 1, 05-21-04) 
 
Changes of size or location do not ordinarily require a special survey.  The provider is  expected to continue to uphold the standards of operation detailed in the most recent 
survey.  Only if the relocation raises significant questions as to the providers ability to 
maintain standards is a resurvey necessary.  However, there may be situations where the 
relocation is so far removed from the ordinary approved site that you conclude that this is 
a different provider/supplier, e.g., different employees, services and patients.  In such 
cases, it may be that the relocation constitutes a cessation of business at the providers old 
location and a voluntary termination on the part of the provider.  Such situations should be 
discussed immediately with the CMS RO.  In deciding whether to advance the resurvey, 
the SA considers the recentness of the last survey, licensure information concerning the 
new arrangement, and whether a phone contact for indicated information (e.g., staffing 
changes) will suffice to resolve questions.  
 
The fact that a new site/building is not shown on the most recent LSC survey report does 
not automatically require the date of the full scheduled resurvey to be advanced.  
However, the SA should ensure that the new location meets the applicable physical 
environment and LSC requirements.  (See 3202 and 3204.)  
 
2704 - SA Presurvey Preparation 
(Rev. 1, 05-21-04) 
 
The SA, in preparation for the survey/resurvey, reviews documents of record including 
licensure records, fire inspection reports, previous survey reports including LSC and 
complaints, media reports about the facility, and other publicly available information 
about the facility (e.g., its own Web site).  This information is helpful in determining 
composition of the survey team and the time required for the survey or resurvey. 
 
If an onsite survey is necessary, the SA schedules the survey in a manner that results in the 
most efficient and effective use of survey staff and that provides the most comprehensive 
look at the facility.  The survey is to be completed promptly and is not to be interrupted by 
other activities. Moreover, in the case of SNFs/NFs, at least ten percent of standard 
surveys must begin on weekends or in the evening/early morning hours.  Of these ten 
percent, the standard survey must be conducted on consecutive days, with all surveyors 
being onsite some or all of those consecutive days. (See 7207 and note.) 
 
The SA reviews the applicable provider/supplier sections of this part to ascertain whether 
other special preparation is needed prior to survey and the SA develops factors such as this 
before the survey is conducted. 
 
2705 - SA Survey Team Workload 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The Survey Team Composition and Workload Report (also referred to as the CMS-670 
report) is an integral part of the overall survey process.  The SA completes this form for 
all survey and/or resurvey activities as it provides necessary information on resource use 
applicable to survey activity of all Medicare, Medicaid-only, and dual participating 
providers and suppliers and CLIA laboratories.   
  The SA follows these guidelines in completing this report: 
 
  If a survey does not include an onsite visit, do not enter arrival, departure, onsite, 
and travel dates or times on the 670.  Enter all other appropriate fields; 
 
  Include on the 670 the time spent by surveyors-in-training who have a surveyor ID 
number.  However, if the trainee simply observes a survey, exclude his/her time 
from the form; 
 
  Report only direct, survey-related time on the 670.  This includes data entry and 
supervisory review time.  Do NOT include general administrative time, such as 
time spent logging onto the CMS Data Center;  
 
  The Type of Survey and Extent of Survey boxes are not required for data entry.  
However, complete these boxes on the 670 since the information may be helpful; 
 
  On a combined certification/State licensure survey, enter the total time (Federal 
and licensure) spent on various phases of the survey, even if you conduct the 
certification survey first, followed by the licensure survey (or vice versa); 
 
  Do not complete the 670 for visits conducted solely for licensure purposes; 
 
  Treat multiple complaints investigated at the same time as one complaint survey 
and enter on one 670; 
 
  If complaints are conducted concurrently with a recertification survey or follow 
up, report the complaint on a separate 670;  
 
  Include in Column D time spent reviewing complaints in-office as pre-survey 
preparation hours if a complaint survey is subsequently conducted; 
 
  Prospective Payment System (PPS) surveys are not entered into CASPER.  
Therefore, do not complete Form CMS-670 for PPS surveys; 
 
  Prepare separate 670s for all health, LSC, complaint investigation, and Federal 
Monitoring Surveys (FMS); 
 
  In cases where the same surveyor performs both health and LSC activities, time 
that cannot be specifically attributed to one survey or the other must be equally 
split between the two 670s (one for health and one for LSC); 
 
  Supervisory review time reported on the 670 is that level of routine review 
normally conducted on all survey reports.  It does not include special quality 
assurance committee review, team leader review, or team review; 
 
  Do not record time spent tracking nurse aide training and competency reviews on 
the 670;   
  In computing travel time, report the lesser of time spent in travel from either the 
surveyors home to site or office to site; 
 
  Enter on the 670 under the appropriate surveyor ID number the time supervisors 
spend participating in a survey (conducting reviews, exit conferences, etc.); 
 
  Assign SA consultants identification numbers in the event that they participate in 
surveys.  Their time should be included on the 670 if they participate; 
 
  If more than 10 surveyors participate in a survey, use continuation forms to input 
survey data into the system.  The CASPER system has been reconfigured to accept 
up to 990 surveyors.   
 
  If errors are made in data entry, change the information by accessing ASPEN 
 
  For supervisors who review a CHOW in house, DO NOT enter the time in 
ASPEN, unless a survey is conducted in conjunction with the CHOW; 
 
  Do not enter QIO staff on the 670 since they are not part of the survey staff; 
 
  Use the 670 only for collecting time spent preparing for, conducting, and finalizing 
a survey of a facility.  Do not capture time spent in hearings after a survey has 
been completed on the 670; and 
 
  Record travel to a patients home as well as time spent in the patients home on an 
HHA survey as onsite time, not travel time. 
 
2706 - SA Survey Team Composition 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Survey team size and composition vary according to the type of provider/supplier and the 
purpose of the survey. For routine SA certification surveys, professional disciplines and 
experience represented by the survey team is to reflect the expertise needed to determine 
compliance with the CoPs, standards, or requirements for that provider/supplier group.  
Also, the SA should consider the history or special characteristics of the provider/supplier 
in selecting members of the survey team.  In all instances, members of the survey team 
must meet education and training qualifications specified in 4009. 
 
In general, the size and type of the provider/supplier govern the size of teams.  ICF/IID 
survey teams are to include personnel with expertise in developmental disabilities, and, 
except for LSC, all members are to survey together during the same time intervals.  (See 
7201 for SNF/NF.) 
 
2708 - Facility Refuses to Allow Survey 
(Rev. 1, 05-21-04) 
  Court decisions, both Federal and State, hold that the acceptance of the Medicare or 
Medicaid agreement or State licensure is implied consent by the institution to permit 
authorized officials to make unannounced visits.  Refusal of access can be a basis for 
termination of participation in Medicare or Medicaid.  (See 42 CFR 489.53.)  If access is 
refused, the SA surveyor documents the identity (name and title) of the individual refusing 
admission and the reason.  The SA indicates what action the State intends to take in 
relation to licensure (if a licensure visit was involved), or in relation to Medicaid if a 
Medicaid-only provider/supplier.  The SA submits this documentation immediately to the 
RO or the SMA, as appropriate. 
 
The SA calls to the attention of the provider/supplier that 42 CFR 1001.1301 permits the 
Office of Inspector General (OIG) to exclude a facility from the Medicare and Medicaid 
programs if, upon reasonable request, it fails to grant immediate access to CMS or the SA.  
The exclusion may be in effect up to a period equal to the sum of the length of the period 
during which immediate access was not granted plus an additional 90 days.  The RO 
makes the referral to the OIG.  (See 1864(c) and 1128(b)(12) of the Act and  
42 CFR 488.6(c) and 489.53(a)(4).) 
 
2710 - Reviewing Forms at Beginning of Survey 
(Rev. 1, 05-21-04) 
 
Request to Establish Eligibility 
 
One of the purposes of the Request to Establish Eligibility (or the equivalent application 
form such as Form CMS-671, Form CMS-3070G, or Form CMS-1572) is to obtain and 
maintain statistical information.  At each resurvey, the provider or supplier completes the 
appropriate request to update the one completed at the previous survey. 
 
If the form does not contain a specific field to indicate initial survey or a resurvey, enter 
the word Resurvey on the upper right corner of the form. 
 
2712 - Use of Survey Protocol in the Survey Process 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Survey protocols are established to provide surveyors with guidance in conducting surveys 
to assess the compliance of providers and suppliers participating in the Medicare and 
Medicaid programs with certain regulatory requirements.  Survey protocols appear in the 
various appendices to this manual. The purpose of the protocols is to provide instructions, 
check lists, and other tools for use both in preparation for the survey and when performing 
the survey.  Survey protocols are to be used by all surveyors to measure compliance with 
Federal requirements.  They are the authorized interpretations of mandatory requirements 
set forth in provisions of the Act, the Public Health Service Act (for laboratories), and the 
regulations. 
 
Survey protocols identify relevant areas and issues to be surveyed as specified in each 
regulation, and, in some cases, the methods to be used to survey those areas and issues.  
These protocols promote consistency in the survey process.  They also assure that a  facilitys compliance with the regulations is reviewed in a thorough, efficient, and 
consistent manner.  At the completion of the survey, the SA should have sufficient 
information to make compliance decisions. 
 
Included in the survey protocols are interpretive guidelines that serve to interpret and 
clarify the CoPs, conditions for coverage, and requirements of participation for specific 
types of entities.  The interpretive guidelines contain authoritative interpretations and 
clarifications of statutory and regulatory requirements and are to be used to make 
determinations about a providers compliance with requirements.  These interpretive 
guidelines define or explain the relevant statutes and regulations and do not impose any 
requirements that are not otherwise set forth in the statute or regulations. 
 
The SA conducts the surveys in accordance with the appropriate protocols, and looks to 
the substantive requirements in the statute and regulations to determine whether a citation 
of noncompliance is appropriate.  The SA bases any deficiency on a violation of the 
statute or the regulations.  The decision of whether there is a violation of the statute or the 
regulations must be based upon observations of the facilitys performance, practices, or 
conditions in the facility. 
 
Where the surveyor sees conditions or practices that are in conflict with a particular 
interpretive guideline, these observations are indications that the applicable provisions of 
the statute or regulation are not met.  To make a determination whether the requirement is 
met, the SA should evaluate the observation in terms of frequency and/or severity of the 
condition or practice. 
 
Moreover, the SA may find that a facilitys deficiencies in meeting statutory or regulatory 
requirements may be based on observations other than those mentioned in the guidelines 
because the guidelines cannot provide an exhaustive, all-inclusive listing of all 
circumstances which might indicate violations of the requirements. 
 
The following is an example of how an interpretive guideline may be used to support a 
deficiency citation: 
 
EXAMPLE 
 
  Requirement: The comprehensive functional assessment of the client must identify 
his/her specific developmental and behavioral management needs. 
 
  Interpretive Guideline: Findings are reported in terms that facilitate clear 
communication.  Diagnoses or imprecise terms and phrases (including, but not limited 
to, developmental level,) in the absence of specific terms are not acceptable. 
 
  Statement of deficiency: 42 CFR 483.440(c)(3)(iii): The comprehensive functional 
assessment must identify the clients specific developmental and behavioral 
management needs. 
This Standard was NOT MET as evidenced by the following: 
    For 2 of the 4 clients reviewed (clients #2 and 3), it was determined by record review 
and staff interview that the facilitys functional assessment process required staff 
merely to identify the clients diagnoses or overall level of functioning without 
identifying the clients specific developmental needs. 
 
The findings include: 
 
  The record of client #3 included 11 evaluations conducted by the professional staff.  
None of these evaluations specified any skill deficits that may have contributed to the 
diagnosis of his reported developmental level of functioning. 
 
This example illustrates how material in the ICF/IID interpretive guidelines can be used to 
support the citation.  The critical factor is whether the evidence relates directly to the 
language of the regulation. 
 
2713 - During Survey 
(Rev. 1, 05-21-04) 
 
2713A - Accompanying Surveyors 
(Rev. 1, 05-21-04) 
 
The surveyors may allow, or refuse to allow, facility personnel to accompany them during 
a survey. Each case is at the SA and the surveyors discretion and is to be worked out with 
facility management.  Facility personnel may be helpful. They may answer questions or 
point out certain concerns to the survey team, thus making the entire process easier.  
Conversely, facility personnel may hinder the surveyor, argue about observed problems, 
and make the survey more difficult.  This is not to be tolerated.  The surveyors may refuse 
to allow facility staff to accompany the team if such behavior occurs.  The surveyors 
should make a decision based on the circumstances at the time of the survey. However, the 
surveyors will always conduct interviews with patients/residents in strict privacy and with 
prior permission of the individuals. 
 
2713B - Physical Contact With Patients/Residents 
(Rev. 1, 05-21-04) 
 
A surveyor is not to touch or examine a patient by himself or herself.  However, in certain 
circumstances it is permissible and necessary to determine the physical condition of 
patients.  For example, if the surveyor believes that blankets or clothing are hiding 
bedsores, bruises, or incontinence, they may remove the coverings and make a 
determination based on observation.  Surveyors must obtain the patients  (or 
representatives) permission prior to making any examination.  A surveyor should request 
that a staff member of the facility interact with the individual as necessary. The health and 
dignity of the patient is always of paramount concern.  A surveyor must respect an 
individuals refusal to be observed. 
 
2714 - Interviewing Key Personnel 
(Rev. 1, 05-21-04)   
At the institution, the surveyors will usually meet with the administrator (or director) or 
supervisors of various departments or services to outline the survey plan.  (In many 
instances one person assumes these roles.)  The surveyors obtain information from them 
and other staff.  During the introductory meeting with the administrator, the surveyor 
alerts him/her that if the facility is planning to record the exit conference, a copy of the 
tape must be made available to the team at the conclusion of the conference.  This can be 
accomplished by using two recorders.  A surveyor is not to accept a promise that a copy 
will be mailed at a later date. 
 
The surveyor interviews the Administrator (or Director) first since he/she is the key person 
in the institution.  There are elements related to each condition that the surveyor might 
need to discuss with the administrator.  He/she will be able to direct the surveyor to other 
staff persons to interview relative to specific standards and other requirements.  However, 
contacts are not limited solely to the key person.  Even if the administrator feels that 
he/she can answer most of the questions, the facts must be verified through review of 
source documents and interviews.  The SA investigation must be complete enough to 
document whether the standards are met and the provider is in compliance with the related 
condition(s) or in substantial compliance with the requirement for SNFs/NFs. 
 
While interviews with the Administrator or DON must necessarily be in depth, the survey 
must not disrupt the facility by protracted interviews of all the staff.  A surveyor should 
use a few well-phrased questions to elicit the desired information.  For example, to 
determine if a staff member is aware of disaster procedures and his/her role in such events, 
simply ask, If you smelled smoke, what would you do? 
 
The surveyor should direct questions to the appropriate personnel.  For example, if 
administration of medications is restricted to certain staff, the surveyor questions the 
personnel charged with this responsibility. 
 
2714.1 - Application of Medicare/Medicaid Requirements to Private Pay 
Patients 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The CoPs/Requirements apply to the entire certified provider/supplier and to all 
patients/residents being served by the certified entity, regardless of payment source unless 
stated otherwise in the regulations.  This means that the surveyors may review the care of 
private pay patients/residents when surveying a Medicare/Medicaid approved provider or 
supplier.  This policy is based on the premise that it is the provider or supplier that is being 
approved, not just the beds of or care provided to Medicare/Medicaid beneficiaries. 
 
Of course, this policy does not apply to patients/residents residing in non-certified portions 
of facilities (e.g., the non-certified portions of SNFs which have only a portion of their 
beds Medicare-certified as a distinct part SNF; or the non-certified buildings on the 
campus of large institutions such as psychiatric hospitals or ICFs/IID).  (See 2048 and 
7016.) 
  In some cases it may not be immediately clear whether a division of the certified 
provider/supplier is covered by the certification.  For example, an HHA may have a 
separate division in the organization that provides personal care attendant or homemaker 
services or that provides services to private pay patients.  Unless the agency can 
demonstrate that the separate division is operated as a separate entity, the CoPs apply to 
all home health services provided by the entire HHA.  If the SA cannot make a clear 
determination, it should consult the RO. 
 
Also, certain provisions of the CoPs/Requirements specifically address patients of certain 
payment sources.  For example, the CoPs for providers of OPT/OSP services contain 
certain requirements that apply only to Medicare patients.  (See 42 CFR 486.155(b)(4).)  
SNF/NF requirements in 42 CFR 483.12(d)(3)(i) state, A nursing facility may charge a 
resident who is eligible for Medicaid... However, when the CoPs/Requirements refer to 
patients, residents, clients, or individuals in general terms and do not specifically limit the 
requirement to Medicare or Medicaid, those regulations apply to all persons served by the 
certified provider/supplier. 
 
2715 - Interviewing Residents Using the LTC Survey Process 
(Rev. 1, 05-21-04) 
 
The surveyors interview residents, family members, or legal guardians to evaluate their 
impressions about the care being provided by the facility.  Residents, members of their 
family, or legal guardians have the right to refuse to be interviewed.  Surveyors must 
respect the confidentiality of information provided by residents or members of their 
families.  Staff personnel should not accompany the surveyors during resident interviews 
unless their presence is requested by the resident being interviewed, the family, or 
guardian.  During the interviews surveyors should refrain from moving or handling 
residents.  This is to be done by a member of the facility staff.  (See Appendix P.) 
 
2716 - Special Survey of Pharmaceutical Service Requirements in SNFs, 
NFs, and ICFs/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Appendix N describes the procedure(s) that must be applied when surveying a SNF/NF or 
ICF/IID for errors in medication dosage, administration, and recording.  When detecting 
irregularities in pharmaceutical record keeping, the surveyor should begin a probe into the 
matter immediately to determine if the errors go beyond record keeping to a more 
extensive problem of medication preparation and administration.  Surveyors should begin 
a deeper probe of the flagged area.  Also refer to the interpretive guidelines for ICFs/IID.  
(See Appendix J.) 
 
2718 - Assistance in Surveying Psychiatric Hospitals 
(Rev. 1, 05-21-04) 
 
2718A - Use of CMS Surveyors 
(Rev. 1, 05-21-04) 
  To participate in Medicare and Medicaid, a psychiatric hospital must meet the special 
medical records and special staffing requirements.  (See 42 CFR 482.61 and 482.62.)  
Surveys to determine whether these requirements are met are to be performed by board-
certified psychiatrists and Masters-prepared psychiatric nurses, and, if necessary, Masters-
prepared psychiatric social workers.  If the SA does not have qualified psychiatric 
personnel to conduct the surveys, CMS strongly encourages using the services of 
specialist surveyors who are under contract with CMS.  All State-owned and operated 
psychiatric hospitals are to be surveyed by CMS contract specialist surveyors to the extent 
possible, depending on availability and the scope of the program.  The SA submits annual 
requests for survey assistance for the subsequent year to the RO in July.  Provide the 
following information for each hospital: 
 
  Name and address of the hospital to be surveyed; 
 
  Number of beds in the certified component (call the hospital and verify whether 
the number of beds in previous records is still accurate); 
 
  Identification of the distinct part, if the entire institution is not a psychiatric 
hospital; 
 
  JCAHO status (i.e., accredited, non-accredited, in appeal);  
 
  Date of last survey; 
 
  Name and telephone number of the SA person responsible for coordinating the 
survey (a SA surveyor should accompany the CMS psychiatric surveyors during 
the survey, if possible); and 
 
  Whether the institution is privately or publicly owned. 
 
Upon receipt of the SA request, the RO forwards a copy to CO.  The SA and the RO will 
receive a memo confirming the dates of scheduled surveys and the names of the surveyors 
that will participate. 
 
In the interest of timely scheduling of complaint and revisit surveys of psychiatric 
hospitals, the RO should initiate requests by telephone to CO. 
 
2718B - CO Responsibility 
(Rev. 1, 05-21-04) 
 
CMS CO contracts with an independent contractor to handle the scheduling of the 
surveys, e.g., notifying SA and RO of dates of survey by letter, names of CMS surveyors, 
and hotel accommodations.   
 
2718C - Survey Responsibility 
(Rev. 1, 05-21-04) 
  CMS surveyors are responsible for the opening conference, the survey of the two special 
Conditions, 42 CFR 482.61 and 482.62, and the exit conference.  They discuss their 
findings at the exit conference.  Following this, the surveyors involvement in the survey 
process ceases.  For further clarification regarding the surveyors findings, contact the RO. 
 
CMS surveyors forward the Psychiatric Hospital Survey Report (Form CMS-724), and all 
necessary documentation for recertifications, follow-up visits, and initial certifications to 
CO. 
 
The completed report is sent by the CMS mental health surveyors to CO within 10 
working days after the survey for review of appropriateness and completeness of 
documentation.  In turn, CO mails the completed report to the RO for their determination 
of compliance or noncompliance along with an informational copy to the SA.  The 
termination process for psychiatric hospitals using CMS mental health surveyors is 
consistent with the 90-day timeframe for other providers.  
 
However, due to the additional administrative process of sending the survey findings to 
CO, day 1 of the 90-day termination timeframe begins on the date of receipt of the 
completed psychiatric survey report in the RO. 
 
When CMS surveyors find either of the two psychiatric special conditions out of 
compliance, they will telephone the findings to CO.  CO will telephone the RO. 
 
2718D - RO Responsibility 
(Rev. 1, 05-21-04) 
 
The RO acts as a liaison between the SA and CO for activities other than those described 
above.  On an annual basis the RO obtains SA requests for psychiatric hospital survey 
assistance and forwards them to CO.  During the year, the RO monitors development of 
statements of deficiencies and PoCs and SA revisit activities for psychiatric hospital 
surveys not performed by CMS surveyors.  The RO is also responsible for determining 
whether the provider has made a credible allegation of compliance and for requesting 
revisits to be made by the CMS surveyors via CO. 
 
If the RO has any questions or problems arising regarding any aspect of the surveys (e.g., 
scheduling of surveys, interpretation of survey findings), it contacts the CO project officer 
responsible for the psychiatric survey program.  The ROs and SAs do not contact CMS 
mental health surveyors directly. 
 
In most cases, if CMS surveyors cite deficiencies that result in a termination action being 
initiated, the CMS surveyors will perform revisit(s) if the provider makes a credible 
allegation of compliance.  (See 3016.)  The CO project officer will notify the RO if the 
SA is to perform the revisit. 
 
2720 - Completing the Survey Report 
(Rev. 1, 05-21-04) 
  2720A - Traditional SRF 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The Medicare/Medicaid SRF is usually a booklet that serves as a check list during the 
onsite survey to determine if the provider or supplier meets the applicable CoPs or 
Conditions for Coverage. These SRFs contain all of the regulations that apply to a given 
provider/supplier.  During the survey, the provider/suppliers conformance with every 
regulation in the booklet is evaluated. 
 
The SRF is still utilized in conducting surveys of most providers/suppliers, including 
hospices, ASCs, ESRDs, CORFs, OPTs, RHCs, and others.  The various editions of the 
LSC are also in the SRF format.  However, the traditional SRF is no longer in use on 
health surveys of SNF/NFs, ICFs/IID, and HHAs.  (See 2720.C. and D.)  The SRF for 
hospitals and swing-bed requirements (both CAH and hospital) are optional note-taking 
tools that are used at the SA or individual surveyors discretion. It is expected that other 
traditional SRFs will be phased out as survey protocols for other providers and suppliers 
are developed.  
 
While the SRF is still in use for most provider types, use of the Automated Survey 
Processing Environment (ASPEN) obviates the need for recording deficiencies on the SRF 
when entering findings into ASPEN through the use of laptop computers.  ASPEN 
automatically generates an official Statement of Deficiencies and Plan of Correction 
(Form CMS-2567).  However, the surveyor should continue to record any information on 
the SRF that is not being collected on Form CMS-2567.  This is especially important on 
initial surveys and adverse actions.  However, surveyors do not duplicate information that 
is on Form CMS-2567.  Instead, surveyors cross-refer to Form CMS-2567 at the 
beginning of the SRF to indicate where any information that would be duplicative has 
been collected. 
Surveyors should continue to use the SRF as a checklist during surveys of those providers 
for which the SRF is required.  If using the SRF for notes, it constitutes pre-decisional 
material and, like the worksheets, is not releasable under the Freedom of Information Act.  
Surveyors must continue to complete the various worksheets provided for the survey.  It is 
still important to maintain accurate notes of observations to support SA findings. 
 
Where ASPEN is not used, surveyors should continue to complete the SRF in its entirety.  
Deficiencies and negative findings are to be explained via narrative or data under 
Remarks.  Surveyors must fully document cases where enforcement action (such as 
termination) may ensue to substantiate the proposed action in the event of a hearing or 
court review, and record the status of each item at the time of the survey in the Yes-No 
or Met-Not Met columns, if applicable.  Surveyors should use all available sources of 
information that will assist them in completing the SRF.  If a standard or other 
requirement is not applicable, and therefore the Yes-No column is not checked, the 
surveyors must give an explanation.  Surveyors document key areas requiring judgment by 
giving their reasoning, and carefully address all explanatory comments to the correct 
computer tag number. 
 
2720B - Specific Items to Consider When Completing SRF  (Rev. 1, 05-21-04) 
 
When using a traditional check-list style SRF, surveyors should support all checks in 
Yes boxes by such statements, charts, or findings as they consider appropriate (e.g., the 
number and type of records examined [personnel, medical], the existence and addresses of 
any multiple sites, special staffing information, hours of operation, the extent of 
compliance with related requirements). 
 
Include comments when: 
 
  The Explanatory Statements section on the SRF requires them; 
 
  The Yes or Met represents an apparent inconsistency with other findings.  For 
example, two or more Requirements or Standards are marked No, yet the 
covering Standard or Condition is marked Yes; 
 
  A No has been changed to a Yes.  (Have the change initialed and dated by the 
individual who made the change); or 
 
  In your judgment, additional information is needed to reflect the degree of 
compliance. 
 
Support Nos or Not Mets by the following: 
 
  A full description of the deficiency; 
 
  Where appropriate, charts, diagrams, and other documentation to clarify the 
description; 
 
  A statement regarding the degree of hazard to health and safety or the effect on the 
quality of care, and how the deficiency relates to other factors and standards; or 
 
  If the deficiency is significant and the covering Standard or Condition is marked 
Yes, the reasoning or judgment used in checking the Yes. 
 
2720C - Completing ICF/IID Survey Report 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Form CMS-3070G-I (see Exhibit 80) is keyed to the CoPs for ICFs/IID in the Medicaid 
program. Surveyors use the form in conjunction with the interpretive guidelines and 
survey procedures for ICFs/IID (see Appendix J) to identify the regulatory requirements 
and corresponding tag numbers on which to assess compliance.  The cover sheet (Form 
CMS-3070G) is the vehicle for direct data entry into OSCAR about pertinent facility, 
individual, and survey-related data.  The first page of Form CMS-3070H, a prototype 
designed to be reproduced to as many pages as needed, is used to record and summarize 
deficiency-related data on the Standards and CoPs.  The last page of Form CMS-3070H 
includes a certification statement for each member of the survey team to sign and date.   This statement attests that each CoP-related Standard has been reviewed, and unless 
indicated on Form CMS-3070H, the facility is found to be in compliance.  In accordance 
with instructions in Appendix J, surveyors complete the optional individual observation 
worksheet for use in conjunction with the survey. 
 
2720D - Completing HHA and SNF/NF Survey Reports 
(Rev. 1, 05-21-04) 
 
The survey reports for HHAs, SNFs, and NFs are no longer the traditional check-list 
style SRFs. Rather, the HHA, SNF, and NF survey reports consist of a variety of forms 
and worksheets used to record information in accordance with outcome-oriented survey 
protocols.  Surveyors complete all required forms and worksheets as instructed in the 
protocols. 
 
2722 - Preparation for Exit Conference (Excluding SNFs and NFs) 
(Rev. 1, 05-21-04) 
 
Surveyors hold a pre-exit survey team conference at the conclusion of the survey prior to 
the exit conference and come to an agreed judgment on the severity of any deficiencies 
and whether their number, character, and combination interfere with the delivery of 
adequate care, and create hazards to patients health and safety.  Deficiencies found in 
more than one CoP or Standard may be cumulative and interrelated and result in general 
or across-the-board inadequacies in patient care as to constitute hazards to patients.  This 
would be the basis for a finding of noncompliance.  Surveyors use the following criteria, 
in part, to make a judgment as to the significance of a deficiency: 
 
  A deficiency exists if a particular requirement is not in compliance; and 
 
  A deficiency is significant if it affects the ability of the institution to provide 
adequate care, or which adversely affects the health and safety of patients.  A 
Standard or an individual requirement (within a CoP) not in compliance may or 
may not be a significant deficiency. 
 
2723 - Citing Deficiencies in SNFs and NFs 
(Rev. 1, 05-21-04) 
 
Refer to Appendix P for instructions. 
 
2724 - Exit Conference 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
Subsequent to the pre-exit conference held to allow team members to exchange and 
formulate survey findings, the surveyors conduct an exit conference (an exit) with the 
entitys administrator, designee, and other invited staff.  The purpose of the exit 
conference is to informally communicate preliminary survey team findings and provide an 
opportunity for the interchange of information, especially if there are differences of 
opinion.  Although it is CMS general policy to conduct an exit conference as a courtesy  to the provider and to promote timely remediation of quality of care or safety problems, be 
aware of situations that would justify refusal to continue an exit conference.  For example: 
 
  If the provider is represented by counsel (all participants in the exit conference 
should identify themselves), surveyors may refuse to continue the conference if the 
entitys attorney attempts to turn it into a evidentiary hearing; or 
 
  Any time the provider creates an environment that is hostile, overly intimidating, 
or inconsistent with the informal and preliminary nature of an exit conference, 
surveyors may refuse to conduct or continue the conference. 
 
Additionally, as discussed in 2714, if the entity wishes to audio tape the conference, it 
must tape the entire meeting and provide the surveyors with a copy of the tape at the 
conclusion of the conference. Videotaping is also permitted if it is not disruptive to the 
conference, if a copy is provided at the conclusion of the conference.  It is at the sole 
discretion of the surveyor(s) to determine if videotaping is permitted. 
 
It is critical that the surveyors establish and maintain control throughout the exit 
conference. Surveyors should present their findings but refrain from arguing with the 
provider.  Be mindful that providers are likely to react defensively to surveyor findings.  
The provider has a right to disagree with the findings and present arguments to refute 
them.  Surveyors should be receptive to such disagreements.  If the provider presents 
information to negate any of the findings, surveyors should indicate their willingness to 
reevaluate the findings before leaving the facility.  The survey teams reasonableness 
demonstrates their fairness and professionalism.  The degree of receptivity displayed by 
providers during the exit conference often depends upon the attitudes and survey style of 
the survey team. 
 
If the LSC survey is conducted independently of the health survey, the fire authority 
conducts a separate exit conference. 
 
The following guidelines are helpful to surveyors in performing an exit conference: 
 
2724A - Introductory Remarks 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
Introduce yourself to those present.  Restate why the survey was conducted.  Express the 
teams appreciation for anything the provider has done to facilitate the survey.  Explain 
that the exit conference is an informal meeting given as a courtesy to the provider to 
discuss preliminary survey findings and thereby assist the provider or supplier in 
developing an acceptable PoC, if appropriate and required.  The tone of the exit 
conference should be professional and constructive.  It is important to communicate that 
the findings are preliminary and could change following State and CMS supervisory 
review. Indicate that official findings are presented in writing on Form CMS-2567 and 
will be forwarded to the provider within 10 working days.  Indicate that the provider will, 
in turn, have 10 calendar days to submit a PoC.  (See 2728.) 
  2724B - Ground Rules 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
Explain how you will conduct the exit conference and how the teams findings will be 
presented; for example, each surveyor may present a portion of the total findings.  Inform 
the provider that where there are disagreements between the team and the provider about 
the findings that cannot be resolved during the conference or before the team leaves the 
facility, the provider will have the opportunity to submit additional evidence to the State, 
and/or the RO through the Plan of Correction process.  (See 2728.B. concerning provider 
attempts to refute survey findings on the Form CMS-2567.) 
 
2724C - Presentation of Findings 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
In presenting preliminary findings, avoid reading your findings or only referring to them 
by their data tag number.  Explain why the findings are a violation of Medicare or 
Medicaid requirements in enough detail to assist the provider in expediting the provider's 
correction of any deficiencies ahead of the formal receipt of the Form CMS-2567.   
 
Non-Long Term Care Providers/Suppliers 
For non-long term care, if the provider/supplier asks for the specific regulatory basis for a 
finding of noncompliance, the surveyors should generally provide the regulatory grouping 
to the extent that the team is not still deliberating which part of the regulation is most 
pertinent.  However, the survey team should avoid identifying the specific tags, as the tag 
codes often identify the Condition- or Standard-level classification for most non-LTC 
deficiencies. Additionally, such specific details should wait for supervisory review.  
 
Long Term Care Providers 
For long term care providers (nursing homes and ICF-IIDs), CMS has invested 
considerable effort to add to the SOM more explanations and resource material under 
many deficiency tag codes that can be of particular use to a facility in understanding 
relevant deficiencies and preparing remedial action.   If the provider asks for the specific 
regulatory basis or the specific tag code, the surveyors should generally provide this 
information (except as noted below), but must always caution the facility that such coding 
classifications are preliminary and are provided only to help the provider gain more 
insight into the issues through the information provided in the interpretive guidance.  If the 
facility does not specifically ask for the regulatory basis or tag, the survey team may use 
its own judgment in determining whether this additional information would provide 
additional insight for the facility. 
However, if the survey team is still deliberating as to which tags will be most pertinent, 
the survey team must not speculate at the exit conference as to the specific tag coding that 
will be applied.  For example, the team may still be deliberating as to whether the finding 
was a care planning deficiency or staff training deficiency.  Similarly, the team may 
believe that additional consultation should occur with other State personnel (e.g., a 
pharmacist) before a specific tag number is assigned to the deficiency finding. In these 
cases the survey team should describe the general area of non-compliance without 
identifying a specific tag code.  This is a judgement to be made by the survey team onsite,  so in preparation for the exit conference the team should deliberate as to the degree of 
detail that will be appropriate to describe at the exit.  This is a survey-specific decision 
based on the evidence gathered.  As described below, states must follow the federal 
process.  State licensure laws do not override the procedures outlined in the federal survey 
process.  States are not permitted to have blanket policies that require surveyors to always 
provide certain information during the Exit conference that differs from the policy 
described in this section. 
 
Under no circumstances, however, would the surveyors provide the Scope and Severity of 
a given deficiency finding (unless there has been a finding of Immediate Jeopardy), as 
such finer degree of possible detail should await supervisory review.  Instead, survey 
teams may describe the general seriousness (e.g., harm) or urgency that, in the preliminary 
view of the survey team, a particular deficiency may pose to the well-being of residents.  
If a provider asks whether the noncompliance is isolated, pattern, or widespread, the 
surveyor should respond with the facts (i.e., noncompliance was found affecting X number 
of residents). 
 
Clinical Laboratories (CLIA) 
For laboratories, given the complexity of the regulations and nature of the survey, the 
surveyors must d indicate to the laboratory that the specific regulatory reference will be 
found in the CMS-2567 report that will be issued.  The laboratory is informed that the 
information discussed in the exit interview is preliminary and the lab management will 
have an opportunity at the exit interview to talk, in general, about the issues that were 
found. 
 
Life Safety Code 
For life safety code surveys, the survey team may follow the procedures for either non-
LTC or LTC, depending on the degree to which, in the judgement of the team, the tag 
codes are important in helping the provider/supplier to understand the nature and location 
of the deficiency, and the corrective actions that would be necessary.  Facility 
representatives are typically invited to accompany life safety surveyors during building 
tours, to improve familiarity with preliminary findings and exit conference proceedings. 
 
For all provider types, under no circumstances should you make general statements such 
as, Overall the facility is very good.  Stick to the facts.  Do not rank requirements.  Treat 
requirements as equally as possible.  Cite problems that clearly violate regulatory 
requirements.  The surveyors must not make statements such as, The condition was not 
met, or The standard was not met. 
 
2724D - Closure 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
When you have completed the exit conference, explain the process to the provider.  Inform 
the provider that the State and/or RO will send a formal statement of deficiencies.  Explain 
the due date for submitting a PoC and how the rest of the certification process works.  If 
you have identified an immediate and serious threat to patient health and safety, explain 
the significance of that finding and the need for immediate corrective action.  In this or  any other instance when adverse action is anticipated, explain the implications.  Make it 
clear that only compliance will stop the adverse action. 
 
In an initial survey, the surveyor tells the provider or supplier to expect notification of 
initial approval or denial of Medicare participation from the RO, and notification by the 
SMA concerning Medicaid participation, if appropriate.  The surveyor explains that the 
RO establishes the effective date of participation and notifies the provider or supplier in 
writing and that Medicare payment will not be made before the effective date.  
 
Notices of Medicare recertification from the RO are not necessarily sent unless there are 
changes in approved services or in sizes of distinct parts certified.  Notices of reapproval 
of NFs and ICFs/IID are made according to State policy. 
 
2726 - Summary of SA Certification Actions Performed After Survey 
(Rev. 1, 05-21-04) 
 
Following are summaries of eight SA steps of the post-survey certification process: 
 
1.  Prepare survey documents for eventual public disclosure. 
 
2.  Send Form CMS-2567 to the provider/supplier, requesting a PoC if appropriate.  A 
PoC is required for all deficiencies except as noted in 2728.B. 
 
3.  If extensive documentation is required for adverse action, gather the necessary 
additional evidence.  Only achievement of compliance stops termination action.  A 
PoC may not be required when termination action is recommended because the 
PoC cannot substitute for Condition-level noncompliance.  Review and evaluate 
the PoC to: 
 
  Ascertain whether compliance is likely to be achieved in a time acceptable 
to you or the RO, as appropriate; and 
 
  Help structure the revisit after a credible allegation of compliance is 
received. 
 
4.  Consider waivers of requirements (if explicitly allowed) that may be appropriate.  
Prepare recommendations accordingly or, in the case of Medicaid-only waivers, 
prepare determinations granting or denying waivers. 
 
5.  Certify compliance or noncompliance. 
 
6.  Assemble all required documentation for transmission to the RO or, in a Medicaid-
only case, to the SMA. 
 
7.  If necessary, schedule a revisit to verify the providers follow-through on 
acceptable PoCs.  Schedule future surveys for the next certification interval, taking 
into account the providers accreditation status if applicable, the anticipated  duration of waivers, and, as required by OBRA 87, flexible survey cycles for 
SNFs, NFs, and HHAs. 
 
8.  Be prepared to modify the revisit schedule for unexpected changes or requested 
changes in providers coverage status or for subsequent changes in compliance 
status. 
 
2727 - Limitations on Technical Assistance Afforded by Surveyors 
(Rev. 154, Issued: 06-10-16, Effective: 06-10-16, Implementation: 06-10-16) 
 
SAs are encouraged to communicate with providers and their associations.  Discussions of 
program requirements and the survey process can result in a better understanding of the 
process by all parties involved.  Further, 1819(g)(1)(B) and 1919(g)(1)(B) of the Act 
mandate that the State conduct periodic educational programs for staff and residents (and 
their representatives) of SNFs and NFs in order to present current regulations, procedures, 
and policies.  (See 1010.D.) 
 
When deficiencies are found during the survey process, the surveyor provides an 
explanation to the provider concerning the deficiency in specific terms as described in 
2724C to help the provider understand why the requirement is not met.  Frequently, the 
explanation will embody the action needed to correct the problem.  In situations where 
there may be several possible causes for the deficiency, it is not the surveyors 
responsibility to delve into the facilitys policies and procedures to determine the root 
cause of the deficiency or to sift through various alternatives to suggest an acceptable 
remedy.  For example, if a provider was cited for maintaining incomplete clinical records, 
specify what is missing - not why it is missing or what process is best for ensuring that the 
records will be complete in the future. 
 
2728 - Statement of Deficiencies and Plan of Correction, Form CMS-
2567 
(Rev. 1, 05-21-04) 
 
Form CMS-2567 (see Exhibit 7) serves several of the following important functions: 
 
  It is the basic document disclosed to the public about the entitys deficiencies and 
what is being done to remedy them;  
 
  It documents the specific deficiencies cited; 
 
  It documents any promises made by the provider/supplier, i.e., the 
provider/suppliers plans for correction and timeframes; and 
 
  It provides an opportunity for the provider to refute survey findings and furnish 
documentation that requirements are met. 
 
The fire authority performing a LSC survey usually completes a separate Form 
CMS-2567.  However, Form CMS-2567 for the LSC and health surveys may either be  combined or processed separately. 
 
When there are no deficiencies (including LSC if applicable), the SA indicates that the 
entity is in compliance with all requirements. Refer to Principle #1 in Appendix 7A, for 
specific guidance on preparing this statement. 
 
The SA mails the provider/supplier a copy of Form CMS-2567 within 10 working days 
after the survey.  If there are deficiencies, the SA allows the provider/supplier 10 calendar 
days to complete and return the PoC.  Requirements pertaining to submittal of the PoC 
can be found in subsection B. 
 
2728A - Statement of Deficiencies 
(Rev. 1, 05-21-04) 
 
The surveyor prepares Form CMS-2567 using the instructions provided in Appendix 7A.  
For each Requirement not met, the surveyor makes a citation that includes the following:  
 
  The prefix and data tag number;  
 
  The deficiency that contains the CFR or LSC reference, the Requirement that is 
not met, and an explicit statement that the Requirement is not met; and 
 
  The evidence to support the deficiency.  
 
If the ASPEN computer database program is used to generate Form CMS-2567s, the 
statement of deficiencies will automatically be generated in the general format required 
by, Appendix 7A and will simply require the surveyor to enter the evidence to support the 
deficiency.  If ASPEN is not used, the surveyor lists all deficiencies in the left column of 
Form CMS-2567 preceded by the data prefix tag.  The data prefix tag is printed to the left 
of the regulatory paragraph on each survey report.  If a waiver is requested, the surveyor 
places an asterisk to the left of any deficiency for which the waiver is recommended. 
 
In instances where the facility is in substantial compliance but a deficiency exists and the 
only data tag on the survey form is for the Condition (e.g., ASCs), the surveyor lists the 
deficiencies, states that no Condition-level deficiency exists, and does not use a data prefix 
tag.  
 
NOTE:  This practice is not allowed in cases where there are prefix data tags for 
Standards and/or elements below the Condition level.  (Requirement for SNFs/NFs.) 
 
Surveyors must express deficiencies clearly and concisely with a regulatory citation for 
each. For examples of proper deficiency citations, refer to Exhibit 7A, Principles of 
Documentation. 
 
2728B - PoC 
(Rev. 1, 05-21-04) 
  Regulations in 42 CFR 488.28(a) allow certification of providers/suppliers (other than 
SNFs and NFs) with deficiencies at the Standard level only if the facility has submitted 
an acceptable PoC for achieving compliance within a reasonable period of time acceptable 
to the Secretary.  Failure to submit a PoC could result in termination of the provider 
agreement as authorized by 42 CFR 488.28(a), 488.456(b)(1)(ii), and 489.53(a)(1).  After 
a PoC is submitted, the surveying entity makes the determination of the appropriateness of 
the PoC.  (See 7500 for SNFs/NFs.) 
 
This reasonable period of time (to achieve compliance) is generally no longer than 60 
calendar days.  Of course, the correction date for a specific deficiency may be less or 
greater than 60 calendar days after the survey depending on the circumstances of the 
deficiency.  The SA should not accept dates for correction routinely for 60 calendar days 
when the deficiency can reasonably be corrected well before 60 calendar days. On the 
other hand, a provider may reasonably require more time than 60 calendar days to correct 
some deficiencies, i.e., those requiring construction, or other deficiencies where correction 
is clearly beyond the control of the provider/supplier.  (See 42 CFR 488.28(b) for further 
guidance on correction dates.) 
 
The provider/supplier cited with deficiencies has the following three options: 
 
  Accept the deficiencies stated on Form CMS-2567 and submit a PoC; 
 
  Record objections to the cited deficiencies on Form CMS-2567 and submit a PoC; 
or 
 
  Record objections to cited deficiencies on Form CMS-2567, do not submit a PoC, 
and provide convincing arguments and documented evidence that the deficiencies 
are invalid.   
 
An acceptable plan of correction must contain the following elements: 
 
  The plan of correcting the specific deficiency.  The plan should address the 
processes that lead to the deficiency cited; 
 
  The procedure for implementing the acceptable plan of correction for the specific 
deficiency cited; 
 
  The monitoring procedure to ensure that the plan of correction is effective and that 
specific deficiency cited remains corrected and/or in compliance with the 
regulatory requirements;  
 
  The title of the person responsible for implementing the acceptable plan of 
correction. 
 
NOTE:  The option to record objections pertains only to the opportunity to refute the 
accuracy of the findings incorporating the deficiency.  Providers/suppliers may not 
refute the professional judgment of the surveyor regarding the level, extent, scope, or  severity of the deficiency.  The surveying agency will consider evidence arguing the 
existence of a deficiency, but will not consider documentation that argues the 
seriousness of the deficiency. 
 
If a provider attempts to refute the deficiencies, the SA reviews the documentation 
submitted by the provider.  If the provider provides the SA with indisputable 
documented evidence that the deficiencies that are the basis for noncompliance are 
invalid, the SA revises Form CMS-2567 to reflect compliance with the 
CoPs/requirements, and certify the provider/supplier upon receipt of an acceptable 
PoC for any remaining deficiencies. 
 
In all three options, the provider or supplier response to the deficiency is entered on the 
right side of Form CMS-2567, opposite the deficiency.  The PoC must include the 
provider/suppliers planned action to correct the deficiency and the expected completion 
date. (See 7500 for further documentation for SNFs/NFs.)  PoCs must be specific and 
realistic, stating exactly how the deficiency was or will be corrected.  The PoC must be 
signed and dated by the administrator or other authorized official.  Additional 
documentation may be attached to Form CMS-2567, if necessary.  If a deficiency has been 
corrected since the survey, this should be indicated on the form along with the 
approximate date of correction. 
 
If the administrator requests additional time to develop the plan, the SA asks that it be 
completed as precisely as present information permits, and that it be followed with a more 
specific plan as early as possible.  The SA advises the administrator to return the PoC to 
them promptly.  Also, the SA informs the administrator that, except for SNFs and NFs, the 
law requires that Form CMS-2567 must be made available for disclosure to the public 
within 90 calendar days of the last day of the survey.  (See 42 CFR 401.133.)  For SNFs 
and NFs, 1819(g)(5) and 1919(g)(5) of the Act require disclosure of Form CMS-2567 to 
the public within 14 calendar days after it is made available to the provider.  In addition, 
the SA advises that a future contact will be made to determine that the corrections have 
been made as agreed. 
 
The provider/supplier should retain a copy of Form CMS-2567 and return the original 
copy to the SA within 10 calendar days of receipt.  If a multi-copied Form CMS-2567 is 
used, the provider retains the fifth copy and returns all other copies to the SA. 
 
As indicated above, the provider/supplier may attempt to refute the deficiency(ies) on 
Form CMS-2567.  If so, the SA tries to resolve the disagreement and document the 
resolution.  If the provider/supplier has attempted to refute a deficiency or deficiencies 
without submitting a PoC, but has not provided the SA with documented evidence that 
successfully refutes the validity of the deficiency, the SA notifies the provider/supplier in 
writing that its arguments are rejected and the reasons for the rejection.  The SA advises 
the provider/supplier that failure to submit an acceptable PoC may result in 
recommendations to terminate its participation.  If the provider then refuses to submit an 
acceptable PoC, the SA recommends termination to the RO (or the SMA for title XIX 
only providers) via a Form CMS-1539.  The SA includes in the termination packet all 
pertinent documentation and correspondence related to the survey in question.    
NOTE:  In the event of noncompliance with the CoPs or requirements for SNFs and NFs, 
a credible allegation of compliance is required before a revisit is conducted.  (See 
3014.) 
 
It is not acceptable under any circumstances for a provider or supplier to allude in any way 
to another provider or to malign an individual on a publicly disclosable Form CMS-2567.  
When this occurs, such statements must be removed and an amended PoC obtained by the 
SA. 
 
2728C - Review of PoCs by SA 
(Rev. 1, 05-21-04) 
 
The SA reviews the provider or suppliers PoC for appropriateness, legibility, and 
completeness.  If the PoC is not properly completed or if there is a question about it, the 
SA contacts the provider or supplier representative to obtain clarification or an appropriate 
modification of the plan.  (See 2728.E.)  If multi-copied Forms CMS-2567 are used, the 
SA retains the fourth copy of Form CMS-2567 in the SA file and associate the remaining 
copies with the certification packet. 
 
2728D - Modifications of PoCs 
(Rev. 1, 05-21-04) 
 
The provider or supplier may submit evidence of correction or a modified PoC to the SA 
at any time. The SA retains a copy of the material in the certification file and forwards the 
original to the RO or SMA, as appropriate.  If the modification does not change the 
certification, it is not necessary to report verification of the corrections until after the next 
scheduled resurvey or revisit. 
 
2728E - Rejection of Unacceptable PoCs 
(Rev. 1, 05-21-04) 
 
If the SA finds that a PoC is not acceptable, it rejects it and seeks an acceptable one from 
the provider in writing.  Generally, changes to the PoC must be made by the 
provider/supplier.  The SA does not amend a PoC without the providers concurrence.  
Changes to a PoC must be signed by the provider/supplier.  However, if the adjustments 
required to the PoC are minor in nature (e.g., the provider failed to include a date for one 
of several deficiencies), the SA may contact the provider by telephone, make the 
necessary adjustments on Form CMS-2567, and then submit the change to the provider. 
 
2728F - Major Deficiencies Requiring Long-Term Correction in 
Hospitals, SNFs, NFs, SNF/NFs, and ICFs/IID 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Some LSC deficiencies will require longer-term PoCs.  For example, the installation of a 
sprinkler system will usually take from 18 to 36 months.  Since PoCs may not be accepted 
for a period to exceed 6 months for SNFs and NFs, and one year for hospitals and  ICFs/IID, the following procedure should be followed: 
 
  A LSC waiver should be recommended for the length of time to correct the 
deficiency including time for design and construction; 
 
  A written schedule of milestones in the design and construction of the corrective 
action should be included in the waiver request to determine if the work is 
progressing in an acceptable manner during any subsequent revisits; e.g., has the 
State Fire Marshall approved the hydraulic plans for the sprinkler system; and 
 
  In the interim, the facility should be certified as Meets LSC based on waivers 
rather than Meets based on a PoC.  
 
2732 - Follow-Up on PoCS 
(Rev. 1, 05-21-04) 
 
2732A - Post-Survey Revisit 
(Rev. 1, 05-21-04) 
 
The SA follows up on all deficiencies cited in PoCs.  In some cases, the cited deficiencies 
may be of a nature that a mail or telephone contact will suffice in lieu of an onsite visit 
(e.g., the facility agreed to amend its bylaws or written policies).  A mail or telephone 
contact is acceptable as long as the SA has no reason to question the validity of the 
reported corrections.  However, an onsite visit is generally required for deficiencies 
concerning quality of care.  Because the LTC survey process focuses on the care of the 
resident, revisits are almost always necessary to ascertain whether the deficiencies have 
indeed been corrected.  (See Appendix P for further instructions about follow-up surveys 
in SNFs and NFs.)  If documentation or onsite verification is warranted, the SA obtains 
appropriate verification before reporting a deficiency as corrected.  The revisit (or the mail 
or telephone contact) requires that the SA complete a Post-Certification Revisit Report 
(Form CMS-2567B). 
 
2732B - Form CMS-2567B (See Exhibit 8) 
(Rev. 1, 05-21-04) 
 
At the time of the follow-up visit to verify corrections of deficiencies previously cited on 
Form CMS-2567 and/or when corrections are verifiable by telephone contact or mail, the 
SA completes Form CMS-2567B for the corrections that have been completed.  The SA 
enters: 
 
1.  Provider or supplier identification information; 
 
2.  Date of the revisit or date of verification; 
 
3.  Prefix tag; 
 
4.  Corresponding regulatory reference cited on the original Form CMS-2567; and    
5.  Date the correction was accomplished. 
 
If possible, the revisit is to be conducted by a member(s) of the survey team who cited the 
original findings.  The SA has the completed form initialed by the reviewing official and 
signed by the surveyor and retains the fourth copy for its provider file, mails a copy to the 
provider or supplier, and forwards a copy to the RO or SMA, as appropriate. 
 
If, at the time of the revisit, some deficiencies have not been corrected, the SA completes 
another Form CMS-2567 summarizing the deficiencies not corrected by data prefix tag 
number.  The SA asks the provider or supplier to provide a revised PoC with new 
completion dates.  The SA annotate under the heading Statement of Deficiencies and 
Plan of Correction, Summary of Deficiencies Not Corrected on a Follow-Up Visit, and 
enters the date of the revisit beneath the date of the survey. 
 
The SA associates the fourth copy of the revised Form CMS-2567 with Form CMS-
2567B, retains a copy for its provider file, sends a copy to the provider or supplier, and 
forwards the remaining copies to the RO or SMA, as appropriate.  The SA considers 
whether the uncorrected deficiencies affect the ability of the provider or supplier to meet 
the CoPs or Requirements.  If they do, the SA documents noncompliance and initiates a 
termination action. 
 
2732C - Notifying Governing Bodies of Continuing Deficiencies 
(Rev. 1, 05-21-04) 
 
Generally, the SA deals directly with the administrator or director on a routine basis.  
However, the SA may notify the governing body if an administrator or director has been 
ineffective in correcting deficiencies.  If the SA does so, it advises the administrator or 
director. 
 
2734 - SA Evaluation of Compliance 
(Rev. 1, 05-21-04) 
 
A qualified surveyor (see 4009) who participated on the survey is expected to coordinate 
the survey teams compilation of all information required to complete the certification and 
is responsible for completing all official reports of survey findings.  Survey findings, per 
se, are not certifications.  However, they determine the type of the certification 
recommendation made.  The SA director or his/her designee makes certifications.  Thus, 
compliance with program requirements is an official finding made by or for the SA 
director. 
 
2734A - Conditions for Certifying Compliance 
(Rev. 1, 05-21-04) 
 
1 - Medicare, Medicaid and CLIA Participants 
 
A participating provider cannot participate in a program, and a suppliers service cannot  be covered, unless it is in compliance with each of the applicable CoPs, Conditions of 
Coverage, or substantially in compliance with the requirements for SNFs/NFs. 
 
2 - Certifying Compliance Based on Acceptable PoC 
 
Certifying compliance based on an acceptable PoC indicates that the CoPs, or Conditions 
of Coverage are substantially met, the provider has submitted an acceptable PoC and/or 
request for an approvable waiver, if needed, and is able to furnish adequate care which 
does not jeopardize the health and safety of patients and residents during the time period 
that the corrections are taking place. (See 7300 for SNFs/NFs.) 
 
If the provider/supplier submits a PoC and/or a request for an approvable waiver, the SA 
evaluates whether the corrective action will result in compliance within a timeframe 
acceptable to CMS or the SA, which is usually 60 calendar days.  (See 2728 for 
acceptable PoCs.)  The PoC may include the providers/suppliers objections to the cited 
deficiencies. 
 
A health or LSC waiver is granted only in accordance with the regulations on the premise 
that patient/resident health and safety are adequately safeguarded. 
 
2734B - Certifying Noncompliance 
(Rev. 1, 05-21-04) 
 
The SA certifies noncompliance based on a provider or suppliers: 
 
  Failure to meet the CoPs, Conditions of Coverage, or substantially meet the 
Requirements for SNFs and NFs; or 
 
  Inability or refusal to submit an acceptable PoC for any other unmet requirement. 
 
Following a certification of noncompliance, the SA follows the procedures for denial, 
termination, or denial of payment in 3000-3040 or Chapter VII for SNFs/NFs. 
 
2736 - The Outcome-Oriented Survey Process 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The outcome-oriented survey process for SNFs, NFs, HHAs and ICFs/IID places 
emphasis on individual outcomes.  The focus of the survey is to determine whether the 
facility is actually providing services rather than whether the facility is capable of 
providing them.  See Appendix P for SNFs and NFs, Appendix B for HHAs, and 
Appendix J for ICFs/IID.  
 
The outcome-oriented survey process for laboratories places emphasis upon performance.  
It determines whether the laboratory is actually providing accurate and reliable results 
rather than whether the laboratory is capable of providing them (see Appendix C). 
 
  2760 - Forwarding SA Certification to RO 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
Only CMS makes the determination to approve or deny a provider or supplier (except for 
FQHCs) for participation in the Medicare program.  The SA transmittal of its findings is a 
recommendation to the RO or MAC for the certification action. The SA certification is 
used as the primary item of evidence to support decisions to approve or deny Medicare 
provider participation or coverage of provider or supplier services.  The SA sends the 
entire certification packet to the RO or MAC for any action other than a routine periodic 
recertification.  In routine recertifications, the SA inputs the data into the national data 
system and, as appropriate, forwards an abbreviated packet of documents to the RO and 
MAC. 
 
The SA completes the appropriate provider worksheet to distill essential information from 
the survey report for input into the national data system.  Each provider worksheet is 
identified by the same form number as the corresponding survey report.  The alpha prefix 
tag number assigned to each survey report data item is listed on the appropriate provider 
worksheet. 
 
The SA completes all pertinent documentation relating to certification actions for each 
provider/supplier or action category and forwards it to the RO or MAC (or State Medicaid 
Administrator (SMA), as appropriate) no later than 45 calendar days after the exit 
interview. 
 
2762 - Medicare/Medicaid Certification and Transmittal, Form CMS-
1539 
(Rev. 1, 05-21-04) 
 
2762A - Purpose of Form CMS-1539 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
The SA uses Form CMS-1539 to certify findings to the RO, MACs or State Medicaid 
Agency (SMA) with respect to a facilitys compliance with Conditions of Participation, 
Conditions for Coverage, Conditions for Certification, or Nursing Home Requirements.  
Form CMS-1539 is also a transmittal cover sheet for the certification packet.  (See Exhibit 
9.) 
 
Together with the SA certification file, Form CMS-1539 constitutes the primary record of 
the determination to approve a provider or supplier.  It may be used with supporting 
documentation in any appellate action.  It is essential, therefore, that the SA completes 
each item fully and accurately.  Each new certification action requires a separate Form 
CMS-1539. 
 
The Form CMS-1539 also exists as an electronic form and is more frequently used than 
the paper version of the form.  The Form CMS-1539 is used to process updates to a 
provider/suppliers information in the national data system. 
  2762B - Definitions of Terms Used on Form CMS-1539 
(Rev. 1, 05-21-04) 
 
1 - Facility 
 
For Form CMS-1539 purposes, facility means the provider entity or the business 
establishment of a provider or supplier that is subject to certification and approval in order 
for the provider or suppliers services to be approved for payment.  If a provider operates 
separate provider institutions or a supplier operates separate businesses, they are regarded 
as separate facilities for Form CMS-1539 purposes.  A LTC facility with a SNF and a NF 
distinct part is one facility, even though the distinct parts are separately certified for 
Medicare and Medicaid.  Although an agency, such as an HHA with subunits, is one 
facility, the subunits must be separately certified.  One enterprise; one facility; one 
certification is NOT always the rule.  Rather, the way CMS assigns provider 
identification numbers determines how many certifications the SA prepares for any given 
institution.  (See 2764.) 
 
2 - Certified Beds 
 
The Medicare/Medicaid program does not actually certify beds.  This term means 
counted beds in the certified provider or supplier facility or in the certified component.  A 
count of facility beds may differ depending on whether the count is used for licensure, 
eligibility for Medicare payment formulas, eligibility for waivers, or other purposes.  For 
Form CMS-1539, all the following are excluded from certified beds: pediatric visitors, 
newborn nursery cribs, maternity labor and delivery beds, intensive therapy beds which a 
patient occupies for only a short time (such as in radiation therapy units), and temporary 
extra beds.  The following are included: designated bed locations (even though an actual 
bed is not in evidence) and beds which a patient occupies for an extensive period of time 
in special care units such as cancer treatment units as well as all routine inpatient beds. 
 
3 - Dually-Participating 
 
Simultaneous participation of an institution, in the Medicare and Medicaid programs.   
 
4 - Distinct Part 
 
The term distinct part refers to a portion of an institution or institutional complex (e.g., a 
nursing home or a hospital) that is certified to provide SNF and/or NF services.  A distinct 
part must be physically distinguishable from the larger institution and fiscally separate for 
cost reporting purposes. An institution or institutional complex can only be certified with 
one distinct part SNF and/or one distinct part NF.  Multiple certifications within the same 
institution or institutional complex are strictly prohibited.  The distinct part must consist of 
all beds within the designated area.  The distinct part can be a wing, separate building, a 
floor, a hallway, or one side of a corridor.  The beds in the certified distinct part area must 
be physically separate from (that is, not commingled with) the beds of the institution or 
institutional complex in which it is located.  However, the distinct part need not be 
confined to a single location within the institution or institutional complexs physical  plant.  It may, for example, consist of several floors or wards in a single building or floors 
or wards that are located throughout several different buildings within the institutional 
complex.  In each case, however, all residents of the distinct part would have to be located 
in units that are physically separate from those units housing other patients of the 
institution or institutional complex.  Where an institution or institutional complex owns 
and operates a distinct part SNF and/or NF, that distinct part SNF and/or NF is a single 
distinct part even if it is operated at various locations throughout the institution or 
institutional complex.  The aggregate of the SNF and/or NF locations represents a single 
distinct part subprovider, not multiple subproviders, and must be assigned a single 
provider number. 
 
5 - Fully Participating 
 
Participation of an institution in its entirety either in the Medicare or Medicaid program, or 
both. 
 
2762C - Distributing Form CMS-1539 
(Rev. 1, 05-21-04) 
 
The SA completes the five copies of Form CMS-1539.  Copies are transmitted as follows: 
 
1.  First copy (white) - to the RO. 
 
2.  Second copy (yellow) - to the RO for a Medicare-only or a dually-participating 
facility, or the SMA for a Medicaid-only facility or any facility with a Medicaid-
only distinct part. 
 
3.  Third copy (pink) - retain for SA files. 
 
4.  Fourth copy (green) - a convenience copy that the SA may use for cross filing. 
 
5.  Fifth copy (blue) - to the SMA.  In the case of a Medicaid-only facility or 
Medicaid-only distinct part, the SMA is to transmit this copy to the RO by to 
indicate the issuance of a provider agreement. 
 
If Form CMS-1539 is computer generated, copies are distributed the same as above. 
 
2762D - Amended Certifications 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
Should the additional information requested via the Regional Office Request for 
Additional Information (Form CMS-1666, see 2776) result in any changes in the 
certification, the SA prepares a new Form CMS-1539 incorporating the additional 
documentation and any resulting changes in the certification.  The SA draws a line 
through the original Form CMS-1539 and note at the top of this form, See amended 
certification dated          .  The SA forwards Form CMS-1539 to the RO or MAC 
indicating in Item 16 that this certification is amending the certification dated_______.     
2764 - SA Completion Instructions for Certification and Transmittal, 
Form CMS-1539, 1-32 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
The main purpose of Form CMS-1539 is to transmit the SAs certification that a facility 
meets or does not meet the requirements for participation.  The SA completes all 
applicable parts of the form for Medicare/Medicaid providers/suppliers.  The SA 
completes items 1-32 as follows: 
Except for the signatures, the SA types (includes keyboard entry) all applicable entries on 
Form CMS-1539. 
 
NOTE: Within each item on Form CMS-1539 there are code numbers for data reduction 
purposes (e.g., (L1), (L2)).   
 
Item 1 - Medicare/Medicaid Provider No 
Leave this item blank on all initial certifications.  CMS assigns the CCN for all new 
providers and suppliers.   
 
CCNs for hospitals and LTC facilities with multiple components and/or distinct parts are 
assigned by the RO using the following criteria: 
 
A - Long-Term Care Facilities (SNF or NF) with Distinct Parts 
 
One CCN is assigned and only one Form CMS-1539 prepared for the following 
situations (see 2779): 
 
  SNF/NF with a SNF or NF distinct part; and 
 
  SNF with a NF distinct part.  
 
B - Distinct Part SNF/NF of Hospitals or CAHs 
 
Two CCNs are assigned, one for the hospital/CAH and one for the SNF/NF.  
Prepare separate Forms CMS-1539 for certification actions regarding each 
provider.  
 
CCN are assigned in the following fashion: 
 
1 - Hospital or CAH with Distinct-Part SNF 
 
Two CCNs are assigned, one for the hospital/CAH and one for the SNF.  Prepare 
separate Forms CMS-1539 for certification actions regarding each provider. 
 
2 - Hospital or CAH with Distinct-Part NF 
 
Two CCNs are assigned, one for the hospital/CAH and one for the NF.  Prepare  separate Forms CMS-1539 for certification actions regarding each provider. 
 
3 - Hospital or CAH with Distinct-Part SNF/NF 
 
 
C -Hospitals or CAHs with Swing-Bed Approval 
 
One CCN is assigned, however the single CCN for the hospital or CAH is modified to 
address the hospitals or CAHs swing-bed approval.   A letter `U or `Z in the third 
space of the CCN is used to identify swing-bed approval designation for a short-term 
hospital or CAH (See SOM section 2779C).  Prepare one Form CMS-1539. 
 
EXAMPLE:  21-0101  Is ABC Hospitals (Short-Term Hospital) CCN 
  21U101  Is ABC Hospitals modified CCN for its swing-bed approval 
 
EXAMPLE:  21-1301 Is XYZ CAHs CCN 
 21-Z301 is XYZ CAHs modified CCN for its swing-bed approval 
 
D Hospital or CAH IPPS Excluded Rehabilitation or Psychiatric Units 
 
Hospitals or CAHs with psychiatric and/or rehabilitation units that are excluded from 
the IPPS are assigned one CCN but will have their CCN modified by adding an alpha 
identifier in the third space to identify their IPPS excluded rehabilitation unit and/or 
psychiatric unit.  IPPS excluded units in CAHs are called distinct part units (DPU).  
(See SOM section 2779C and 2779C1)  Prepare one Form CMS-1539.   
 
Item 2 - State Vendor or Medicaid Number 
The SA completes this item only for those States that assign separate vendor (or Medicaid 
ID) numbers for internal controls or for billing purposes.  The SA should leave this item 
blank if a State does not have such a system. 
 
Item 3 - Name and Address of Facility 
 
The facility properties screen of the national data system automatically generates the 
name, physical address, city, State, and zip code of the facility. A post office box without 
a street address is not sufficient. 
 
Item 4 - Type of Action 
 
In the block provided, the SA enters the appropriate code in accordance with the following 
explanations:  
 
Code 1 (Initial Survey) 
 
In addition to initial certifications, the SA selects this code when recommending an 
initial denial of participation.  The SA indicates in Item 15 that it is recommending 
denial.    
Code 2 (Recertification) 
 
The SA selects this code when conducting a recertification survey. 
 
Code 3 (Termination or retirement of CCN) 
 
The SA selects this code for involuntary termination, voluntary termination/withdrawal, or 
change in status requiring a new CCN.  Examples of a change in status includes:  
 
  When a hospital converts to a CAH,  
 
  When a CAH converts to a hospital, 
 
  When a short-term hospital reclassifies to become an IPPS-excluded hospital, 
 
  When an IPPS-excluded hospital reclassifies to become another classification 
of hospital (Short-term hospital or IPPS-excluded hospital), or 
 
   When a hospital undergoes a CHOW and then is combined with another 
hospital the new owner already owns. 
 
Code 4 (CHOW) 
 
The SA selects this code for a CHOW situation.   
 
Code 5 (Sample Validation) 
 
The SA selects this code for a complete survey in an accredited facility for sample 
validation purposes.  The SA completes all appropriate blocks on the form including 
items 6 (survey date), 8 (accreditation status), and 10 (compliance provision). 
 
Code 6 (Complaints) 
 
The SA selects this code for an onsite complaint investigation. 
 
Code 7 (Onsite Visit) 
 
The SA selects this code for an onsite inspection of a facility for some other reason 
not outlined above.  Examples include: 
 
1.  Onsite revisit to verify that the deficiencies cited on the original survey are 
corrected and a Form CMS-2567B is completed; 
 
2.  Onsite visit to verify that a hospital or CAH meets the criteria for hospitals or 
CAHs operating with swing-beds or IPPS-excluded units; and 
  3.  Onsite visit to verify that an HHAs satellite meets the branch criteria.  
 
      Code 8 (Full Survey After Complaint) 
 
The SA selects this code for when a full survey after a complaint investigation is 
completed in the complaint system. 
Code 9 (Other) 
 
The SA selects this code for any certification action not specified above (e.g., changes 
in effective date, size, facility name, or address).  Whenever action code 9 is selected, 
the SA shows in Remarks, Item 16, and the reason for completing Form CMS-1539. 
 
Item 5 - CHOW Date 
 
When Item 4 is marked CHOW (code 4), the SA is unable to enter the date the change 
occurred (e.g., 060782) in Item 5.  CMS will enter the date the change occurred.    
 
Item 6 - Survey Date 
  
For providers who require a life safety code (LSC) survey, the SA enters the date the 
health or LSC survey is completed, whichever is later.  For providers and suppliers who 
do not need a LSC survey, the SA enters the date the health survey is completed (e.g., 
060283). 
 
Item 7 - Provider/Supplier Category 
 
In the block provided, the code that is most descriptive of the facility identified on the 
form is taken.  The SA does not manually enter a code.   
 
Item 8 - Accreditation Status 
 
The SA does not manually enter accreditation status on this form.  It is taken from the 
information already entered into the deemed tab of the certification kit and populated on 
the form.  
 
Item 9 (L35) - Fiscal Year Ending Date 
 
The MAC or CMS PEOG, when applicable, enters the ending date (month and day) of the 
providers/suppliers fiscal year (e.g., 0630). 
 
Item 10 - State Agency Certification 
 
A - In Compliance With Program Requirements 
 
If A is entered in the first block and the facility is not in full compliance with the 
program requirements, all conditional aspects are coded in the blocks following A.  
For example, the SA enters A126 when a hospital is in compliance with the program  requirements based on an acceptable PoC, recommended waivers for technical 
personnel, and limited scope of service. 
 
NOTE:  A1 applies to all provider/suppliers with an acceptable PoC. 
  A2 and A6 apply to hospitals only. 
  A3 applies to hospitals, SNFs, and NFs only. 
  A4 is no longer applicable. 
  A8 and A9 apply to all LTC facilities. 
  A5 applies to all facilities that undergo a fire safety survey. 
  A7 no longer applies to SNFs. 
 
B - Not in Compliance With Program Requirements (Termination Development) 
 
If B is entered in the first block, the documentation supporting the termination 
action must accompany Form CMS-1539 and be referenced in Item 16 of Remarks.  
Item B is also selected when an accredited hospital is not in compliance with one or 
more of the CoPs surveyed during the sample validation survey or complaint 
investigation. 
 
C - Not in Compliance With Program Requirements (Denial of Payments for New 
Admissions for SNF, NF, and ICF/IID)  
 
1 - Denial of Payments Recommended 
 
The SA marks B in the first block when a recertified SNF, NF, or ICF/IID is not 
in compliance with the program requirements and is a likely candidate for denial of 
payments for new admissions.  The SA annotates Item 16, Remarks to indicate 
that a denial of payments may be applied. 
 
2 - Resurvey Finds Substantial Compliance 
 
Following a revisit, the SA marks A in the first block when the facility is found 
to be in substantial compliance with the program requirements.  The SA annotates 
Item 16, Remarks to show that the denial of payments for new admissions 
should be ended. 
 
D - Resurvey Does Not Find Significant Progress 
Following the revisit, the SA marks B in the first block when a facility is still not in 
compliance with program requirements and significant progress in correcting the 
deficiencies cannot be documented.  The SA annotates Item 16 Remarks to show 
that the denial of payments for new admissions should remain in effect or that a 
termination action is being initiated. 
 
NOTE: In all cases, the appropriate SA documentation must accompany Form 
CMS-1539. 
 
Item 11 - LTC Period of Certification 
  TLAs are no longer required for ICFs/IID.  The SA does not need to insert the 
recommended beginning (FROM) and ending (TO) dates of the TLA.   
 
Item 12 - Total Facility Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) 
The SA enters the total number of beds in the facility, including those in non-participating 
and non-licensed components or areas.  The Number of Beds in the Certified Portion of 
the Facility Must Not Exceed the Number of Total Beds. 
 
NOTE:  The number of total facility beds and beds in the certified portion of the facility 
on Form CMS-1539 is restricted to the entire facility or the distinct part identified in Items 
1 (CCN) and 7 (Provider Category). 
 
Item 13 - Total Certified Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) 
 
The SA enters the number of beds in Medicare and/or Medicaid certified areas. 
 
Item 14 - SNF, NF, and ICF/IID Certified Bed Breakdown 
 
The total number of beds in the certified portion of the facility recorded in Item 13 must 
be divided in Item 14 according to type of program (i.e., Box A-18 SNF, Box B-18/19, 
Box C-19 NF, and Box E-ICF/IID).  Boxes D and F are no longer applicable.   
 
The SA completes boxes A, B, C, and E, as appropriate.  These blocks must equal Item 
13 (total beds in the certified portion of the facility). 
 
The examples on the following pages illustrate how Items 1 (CMS Certification Number) 
and 7 (Provider category) must be completed in conjunction with Items 12-14 for all 
hospital, SNF, NF, and ICF/IID providers. 
 
Item 15 - Nonparticipating Emergency Hospitals and NFs 
 
The SA enters code 1 or 2 in the block provided. 
 
The SA completes this block when a nonparticipating hospital meets the definition of an 
emergency hospital (see 42 CFR 424, Subpart G) in order to claim payment for emergency 
services rendered to Medicare patients.  For participating NFs, the SA enters the 
appropriate code when the facility meets, or does not meet, the 1861(j) of the Act 
definition for durable medical equipment (DME) and home health benefit purposes. 
 
Item 16 - State Survey Agency Remarks 
 
The SA uses this space for any required remarks or recommendations for approval or 
disapproval.  The SA should list the names of the surveyor and the SA approval in this 
space. 
 
If the comments exceed the allotted space, the SA continues on a sheet of paper entitled 
Item 16 Continuation for CMS-1539.  The SA includes the provider number, if known,  on the sheet for identification purposes.  Whenever Item 4 is completed as Other, the SA 
uses Remarks to indicate the reason for completing Form CMS-1539.  The following is 
a list of remarks which must be entered whenever appropriate. 
Remarks  SOM Reference 
   
Exclusion from Certification (Non-PPS)  2026, 2048, 2134, and 
7016 
   
Loss of Deemed Status Accreditation   2005B 
   
Certification of Additional Services  3220, 3222 
   
RHC Furnishes Home Health Services Determine Whether  2246 
in HHA  Shortage Area 
    
Waiver(s) Recommended  2030, 2140, 2248, 
2480, 7014 
   
Multiple Locations  2024, 2182, 2184, 
2302, 2344 
   
Denial of Payments Is Recommended  3006, 7506 
 
 
EXAMPLE 1 
 
1. CCN 
 
| X | X | 0 | 0 | 0 | 0 |  (Hospital) 
 
7.              12.                  13. 
CATEGORY        TOTAL FACILITY BEDS    TOTAL CERTIFIED BEDS 
 
| 0 | 1 | (Hospital)              3 0 0                   3 0 0     
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF  |   /NF  |  NF   |   ICF/IID  |   
 
EXAMPLE 2:  A total of 250 beds are in the combined hospital and DP SNF/NF  
 
Beds are distributed as follows: 
200 beds in hospital portion  
50 beds Title 18/19 DP SNF/NF 
  NOTE: Prepare two Forms CMS-1539 identifying the separate hospital and SNF/NF 
providers. 
 
1. CCN 
                                    
| X |  X |  0 |  0 |  0 |  0 | (Hospital) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0|1 |(Hospital)               2 0 0                     2 0 0         
 
14.  
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
1. CCN 
       
| X |  X |  5 |  0 |  0 |  0 | (SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
      
| 0|2|(SNF/NF)                  5 0                         5 0           
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                   50 
 
EXAMPLE 3: A Total of 400 beds are in the hospital and the DP NF 
 
Beds are distributed as follows: 
300 hospital beds 
100 beds Title 19 DP NF 
 
NOTE: Prepare two Forms CMS-1539 for hospital and LTC components. 
 
1. CCN 
 
| X | X  | 0  | 0  | 0  | 0  | (Hospital) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
  |0 |1 |(Hospital)                  3 0 0                    3 0 0          
14. 
LTC Certified Bed Breakdown   
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
1. CCN 
 
| X | X  |A,E, or F | 0  | 0  | 0  | (Title 19 NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|1 |0 |  (NF                 1 0 0                        1 0 0         
Distinct Part) 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID |  
                               100 
 
EXAMPLE 4:  44 bed hospital with swing-bed approval 
 
1. CCN 
       
| X |  X |  0 |  0 |  0 |  0 | (Hospital) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0| 1| (Hospital)                 4 4                          4 4          
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |  
 
EXAMPLE 5:  100 bed nursing home (free-standing) 
 
Beds are distributed as follows: 
60 beds certified for Medicaid 
40 beds not participating in either Medicare or Medicaid 
 
1. CCN 
 
(NF6:  75 Medicaid NF CCN| X | X |A, E, or F|  0 |  0 |  0 | (NF)  7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
        
| 1| 0 |(|  (NF)                   7 5                          7 51 0 0         
               6 0           
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |  
                                60 
 
EXAMPLE 6:  75 bed Medicaid NF (free-standing) 
 
1. CCN 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                                75 
 
EXAMPLE 7: 150 bed SNF/NF and NF 
 
Beds are distributed as follows: 
100 beds SNF/NF 
50 NF beds  
 
1. CCN 
 
| X | X  | 5  | 0  | 0  | 0  |  (Title 18 & 19 SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|0 |3 |(SNF/NF)                1 5 0                      1 5 0          
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                  100        50 
 
EXAMPLE 8:  100 SNF/NF facility 
 
100 beds - SNF/NF dually participating 
 
NOTE: Blocks A-E within item 14 must not exceed the total number of certified beds 
recorded in item 13.  Report dually-participating beds in block B (18/19 SNF).  Block F is 
no longer applicable. 
1. CCN    
|  X|  X |  5 |  0 |  0 |  0 |  (18/19 SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0| 2| (SNF/NF               1 0 0                         1 0 0        
         Dually- 
         Participating) 
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
                  100 
 
EXAMPLE #9:  125 bed SNF/NF facility 
 
Beds are distributed as follows: 
100 beds - Title 19 NF  
25 beds -   Title 18/19 SNF/NF DP 
See Example #8 Note. 
 
1. CCN 
 
| X |  X |  5 |  0 |  0 |  0 |  (18/19 SNF/NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
        
| 0 | 3|(SNF/NF)              1 2 5                       1 2 5         
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                   25        100 
 
EXAMPLE 10:  150 bed Medicaid-only NF 
 
Beds are distributed as follows: 
125 beds - Title 19 NF 
25 beds - not participating in Medicare or Medicaid 
 
1. CCN 
  | X |  X |A, E, or F |  0 |  0 |  0 |  (Title 19 NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1 | 0| (NF)                 1 5 0                         1 2 5        
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                               125                            
 
EXAMPLE 11:  140 bed NF (free-standing) 
 
1. CCN 
 
| X | X  |A, E or F | 0  | 0  | 0  |  (NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1| 0| (NF)                 1 4 0                        1 4 0        
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                              140                   | 
 
EXAMPLE #12 - 30 bed ICF/IID (free-standing) 
 
1. CCN 
 
| X |  X |  G |  0 |  0 |  0 |  (ICF/IID)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1| 1| (IMR)                  3 0                          3 0          
 
14.  
LTC Certified Bed Breakdown   
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                                                30                          | 
  EXAMPLE #13 - 50 bed NF and ICF/IID facility 
 
Beds are distributed as follows: 
30 beds - Title 19 NF 
20 beds - Title 19 ICF/IID 
 
NOTE: Prepare two Forms CMS-1539 identifying the NF and ICF/IID components. 
 
1. CCN 
 
| X |  X |A, E, or F |  0 |  0 |  0 |  (NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1|0 | (NF)                 3 0                          3 0          
 
14. 
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                                30        
 
1. CCN 
 
| X |  X |  G |  0 |  0 |  0 |  (ICF/IID)                2 0                           2 0           
 
14. 
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |   
                                                20 
 
Item 17 - Surveyor Signature 
 
The surveyor (or survey team leader) signs and dates Form CMS-1539 after ensuring that 
the certification documents are complete and accurate. 
 
Item 18 - State Agency Approval 
 
The authorized representative of the SA signs and dates Form CMS-1539 and forwards the 
certification material to the MAC, when applicable or State Medicaid Agency (SMA), as 
appropriate.  His/her signature constitutes for Medicare the official certification that the 
information being reported is correct according to official State files.  In Medicaid-only 
cases, the SA representatives signature on this document represents the adjudicative 
decision of the SA on the qualifications of the institution to participate in the Medicaid 
program.   
Item 19 - Determination of Eligibility 
 
Enter code 1 or 2 in this block of the SAs findings and certifications.  Enter code 1 when 
the provider/supplier is found eligible to participate in the Medicare and/or Medicaid 
programs.  Also enter code 1 when a denial of payment for new admissions is imposed, 
continued, or lifted.  Enter code 2 when a facility is not eligible to participate. 
 
Item 20 - Compliance with Civil Rights Act (Title VI) 
 
For providers/suppliers needing Office for Civil Rights (OCR) clearance, enter code 1 in 
the available block if the OCR requirements are met.  If not in compliance with Title VI of 
the Civil Rights Act of 1964, as implemented by 45 CFR part 80, enter code 2 in the box 
that indicates that the provider is not eligible to participate.  For Medicare Part B suppliers 
not requiring OCR clearance to participate, enter code 3 that indicates not applicable. 
 
Item 22 - Original Date of Participation 
 
Complete for initial certifications only.  Determine when the facility is eligible to begin 
participation in Medicare and/or Medicaid.  Enter the recommended effective date at block 
L24.  The effective date of participation is established pursuant to 42 CFR 489.13 for 
Medicare and 42 CFR 431.108 for Medicaid. 
 
Items 23-25 - ICF/IID Certification Period (LTC Agreements) 
 
When an ICF/IID is found not to be in compliance with program requirements and a 
denial of payment for new admissions is imposed, enter the beginning (Item 23) and 
ending (Item 24) dates of the current re-certification survey.  In Item 25 (extension date), 
enter a date not exceeding the end of the fifteenth month following the month in which 
the sanction will be imposed. 
 
Item 26 - Termination Action 
 
If a providers or suppliers participation in the Medicare/Medicaid program ends, record 
the reason (see below) in the accompanying block.  Also complete Item 28 (termination 
date). 
 
1 - Voluntary 
 
Code 1 - Enter when a facility closes or merges. 
 
Code 2 - Enter when a provider or supplier is voluntarily withdrawing because of 
dissatisfaction with reimbursement. 
 
Code 3 - Enter when a facility is leaving the program because it is at risk of being 
involuntarily terminated. 
  Code 4 - Enter when a provider or supplier no longer wishes to participate in the 
program for some other or unknown reason. 
 
2 - Involuntary 
 
Code 5 - Enter when a facility fails to meet health or safety requirements (Conditions of 
Participation, Conditions for Coverage, Conditions for Certification, or Nursing Home 
Requirements). 
 
Code 6 - Select this code when a provider fails to meet the terms of their agreement. 
 
NOTE: If code 5 or 6 is selected, then the National Practitioner Data Bank (NPDB) 
appeal status box is generated in the national data system.  The options to select are: 
1  No appeal, termination final 
2  Appeal in progress 
3  All appeals exhausted, termination final 
 
3 - Other 
 
Code 7 - Select this code when you terminate a currently assigned CCN.  Examples 
include: 
 
  Medicare SNF or dually-participating SNF/NF elects to participate in the Medicaid 
program only; 
 
  Medicaid NF elects to participate in the Medicare or Medicare and Medicaid 
programs; and 
 
  An ASC, ESRD, or RHC elects to participate as free-standing instead of hospital-
based and vice versa. 
 
In any of the above instances, CMS terminates the existing CCN (complete Items 26 and 
28) and assigns the new CCN.  (See 1060.A.) 
 
Item 27 - Intermediate Sanctions (ICF/IID Only) 
 
When an ICF/IID is found not to meet the requirements of 1905(d) of the Act and the 
decision is made to impose an intermediate sanction rather than terminate participation, 
complete the pertinent items on Form CMS-1539 as follows: 
 
1 - Suspension of Admissions 
 
Enter the date in Item 27A that payments for new admissions in the ICF/IID will be 
denied.  In addition, mark Item 10 with B (not in compliance with program 
requirements).  Mark Item 19 1 (facility is eligible to participate).  In Item 25 
(extension date), enter a date not exceeding the end of the eleventh month following 
the month in which the denial of payments will be imposed.  This date may not be  extended. 
 
2 - Rescind Suspension Date 
 
a - Significant Compliance with Program Requirements 
 
Enter the date the denial of payment is rescinded. 
 
The SA will mark Item 10 A (in compliance with program requirements) and 
Item 19 1 (eligible to participate).  In Item 27B, the RO enters the date the denial 
of payment is rescinded. 
 
NOTE: Items 23 and 24 can only be completed when Item 10 is marked A (in 
compliance with program requirements). 
 
b -Significant Effort or Progress 
 
Item 27b may also be completed when Item 10 is marked B (facility is not in 
compliance with program requirements) and Item 16 (SA Remarks) is documented 
to show that effort and progress has been made to correct the deficiencies.  Item 25 
(ICF/IID extension date) remains unchanged.  Mark Item 19 with 1 (facility is 
eligible to participate). 
 
NOTE: Pursuant to 42 CFR 442.119(a), the denial of payment for new admissions is to be 
rescinded if the facility has corrected deficiencies or can document it is making good faith 
efforts to achieve compliance with the conditions of participation.  Good faith efforts 
would not, however, constitute compliance with program requirements.  Therefore, it is 
conceivable that: 
 
  The denial of payments could be rescinded; 
 
  Effort and progress would be documented; 
 
  The SA would certify not in compliance; and 
 
  The extension would remain in effect. 
 
If the noncompliance deficiencies are not corrected by the 11th month following the initial 
month of denial, the ICF/IIDs provider agreement must be terminated pursuant to 42 CFR 
442.119. 
 
NOTE: Similar information for SNFs/NFs is extracted from the Form CMS-462L, 
Adverse Action Extract for SNFs and NFs. 
 
Item 28 - Termination Date 
 
Enter the effective date of the termination action specified in Item 26.   
Item 29  MAC Number 
 
Enter the five-digit number assigned to the MAC servicing the provider or supplier of 
health services. 
 
Item 30  Remarks 
 
Use this block for any remarks that cannot be covered in the structured items above.  If 
comments exceed space allotted in this item, document the additional comments on a 
sheet of paper entitled:  Item 30, Continuation for Form CMS-1539. 
 
Item 31  RO or MAC Receipt of Form CMS-1539 
 
Enter the date that a certification package is received. 
 
For Medicaid-only providers, the SMA forwards the certification materials to the RO 
following review and completion.  For Medicare, the SA forwards the package directly to 
the RO or MAC. 
 
Item 32 - Determination Approval 
 
Following review of the certification documents an authorized CMS or SMA 
representative must sign and date Form CMS-1539. 
 
2764A - In Compliance With Program Requirements 
(Rev. 1, 05-21-04) 
 
If A is entered in the first block and the facility is not in full compliance with the 
program requirements, all conditional aspects are coded in the blocks following A.  For 
example, the SA enters A126 when a hospital is in compliance with the program 
requirements based on an acceptable PoC, recommended waivers for technical personnel, 
and limited scope of service. 
 
NOTE:  A1 applies to all provider/suppliers with an acceptable PoC. 
  A2 and A6 apply to hospitals only. 
  A3 applies to hospitals, SNFs, and NFs only. 
  A4 is no longer applicable. 
  A8 and A9 apply to all LTC facilities. 
  A5 applies to all facilities that undergo a fire safety survey. 
  A7 no longer applies to SNFs. 
 
2764B - Not in Compliance With Program Requirements (Termination 
Development) 
(Rev. 1, 05-21-04) 
 
If B is entered in the first block, the documentation supporting the termination action  must accompany Form CMS-1539 and be referenced in Item 16 of Remarks.  Item B is 
also selected when an accredited hospital is not in compliance with one or more of the 
CoPs surveyed during the sample validation survey or complaint investigation. 
 
2764C - Not in Compliance With Program Requirements (Denial of 
Payments for New Admissions for SNF, NF, and ICF/IID) 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
1 - Denial of Payments Recommended 
 
The SA marks B in the first block when a recertified SNF, NF, or ICF/IID is not in 
compliance with the program requirements and is a likely candidate for denial of 
payments for new admissions.  The SA annotates Item 16, Remarks to indicate that a 
denial of payments may be applied. 
 
2 - Resurvey Finds Substantial Compliance 
 
Following a revisit, the SA marks A in the first block when the facility is found to be in 
substantial compliance with the program requirements.  The SA annotates Item 16, 
Remarks to show that the denial of payments for new admissions should be ended. 
 
2764D - Resurvey Does Not Find Significant Progress 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
Following the revisit, the SA marks B in the first block when a facility is still not in 
compliance with program requirements and significant progress in correcting the 
deficiencies cannot be documented.  The SA annotates Item 16 Remarks to show that 
the denial of payments for new admissions should remain in effect or that a termination 
action is being initiated. 
 
NOTE:  In all cases, the appropriate SA documentation must accompany Form 
CMS-1539. 
 
Item 11 - LTC Period of Certification 
 
TLAs are required for ICFs/IID.  The SA inserts the recommended beginning (FROM) 
and ending (TO) dates of the TLA.  If ICFs/IID are not in compliance with the CoPs, the 
SA establishes a conditional period of certification subject to automatic cancellation.  
When this occurs, the SA includes the cancellation date in Item 16, Remarks. 
 
Item 12 - Total Facility Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) 
 
The SA enters the total number of beds in the facility including those in non-participating 
and non-licensed components or areas.  The Number of Beds in the Certified Portion of 
the Facility Must Not Exceed the Number of Total Beds. 
 
NOTE:  The number of total facility beds and beds in the certified portion of the facility  on Form CMS-1539 is restricted to the entire facility or the distinct part identified in Items 
1 (Provider Number) and 7 (Provider Category). 
 
Item 13 - Total Certified Beds (Complete for Hospitals, SNFs, NFs, and ICF/IIDs) 
 
The SA enters the number of beds in Medicare and/or Medicaid certified areas. 
 
Item 14 - SNF, NF, and ICF/IID Certified Bed Breakdown 
 
The total number of beds in the certified portion of the facility recorded in Item 13 must 
be divided in Item 14 according to type of program (i.e., Box A-18 SNF, Box B-18/19, 
Box C-19 NF, and Box E-ICF/IID).  Boxes D and F are no longer applicable.   
 
The SA completes boxes A, B, C, and E, as appropriate.  These blocks must equal Item 
13 (total beds in the certified portion of the facility). 
 
The examples on the following pages illustrate how Items 1 (Provider number) and 7 
(Provider category) must be completed in conjunction with Items 12-14 for all hospital, 
SNF, NF, and ICF/IID providers. 
 
Item 15 - Nonparticipating Emergency Hospitals and NFs 
 
The SA enters code 1 or 2 in the block provided. 
 
The SA completes this block when a nonparticipating hospital meets the definition of an 
emergency hospital in order to claim payment for emergency services rendered to 
Medicare patients.  For participating NFs, the SA enters the appropriate code when the 
facility meets, or does not meet, the 1861(j) of the Act definition for durable medical 
equipment (DME) and home health benefit purposes. 
 
Item 16 - State Survey Agency Remarks 
 
The SA uses this space for any required remarks.  If the comments exceed the allotted 
space, the SA continues on a sheet of paper entitled Item 16 Continuation for 
CMS-1539.  The SA includes the provider number, if known, on the sheet for 
identification purposes.  Whenever Item 4 is completed as Other, the SA uses 
Remarks to indicate the reason for completing Form CMS-1539.  The following is a list 
of remarks which must be entered whenever appropriate. 
 
Remarks  SOM Reference 
   
Exclusion from Certification (Non-PPS)  2026, 2048, 2134, and 
7016 
   
Loss of Accreditation - Will be Surveyed on _________  2022.C 
   
Certification of Additional Services  3220, 3222  Remarks  SOM Reference 
   
RHC Furnishes Home Health Services Determine Whether  2246 
in HHA  Shortage Area 
    
Waiver(s) Recommended  2030, 2140, 2248, 
2480, 7014 
   
Multiple Locations  2024, 2182, 2184, 
2302, 2344 
   
Denial of Payments Is Recommended  3006, 7506  EXAMPLE 1 
 
1.  Provider Number 
 
| X | X | 0 | 0 | 0 | 0 |  (Hospital) 
 
7.              12.                  13. 
CATEGORY        TOTAL FACILITY BEDS    TOTAL CERTIFIED BEDS 
 
| 0 | 1 | (Hospital)              3 0 0                   3 0 0     
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |   
 
  EXAMPLE 2:  250 bed hospital 
 
Beds are distributed as follows: 
200 beds in hospital portion  
50 beds Title 18/19 DP SNF/NF 
 
NOTE:  Prepare two Forms CMS-1539 identifying the hospital and SNF/NF components. 
 
1.  Provider Number 
                                    
| X |  X |  0 |  0 |  0 |  0 | (Hospital) 
 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0|1 |(Hospital)               2 0 0                     2 0 0         
 
 
14.  
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
 
1.  Provider Number 
       
| X |  X |  5 |  0 |  0 |  0 | (SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
      
| 0|2|(SNF/NF)                  5 0                         5 0           
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                   50 
  EXAMPLE 3:  400 bed hospital 
 
Beds are distributed as follows: 
300 hospital beds 
100 beds Title 19 DP NF 
 
NOTE:  Prepare two Forms CMS-1539 for hospital and LTC components. 
 
1.  Provider Number 
 
| X | X  | 0  | 0  | 0  | 0  | (Hospital) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|0 |1 |(Hospital)                  3 0 0                    3 0 0          
 
 
14. 
LTC Certified Bed Breakdown   
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
 
1.  Provider Number 
 
| X | X  |A,E, or F | 0  | 0  | 0  | (Title 19 NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|1 |0 |  (NF                 1 0 0                        1 0 0         
Distinct Part) 
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID |  
                               100 
     EXAMPLE 4:  44 bed hospital swing-bed facility 
 
1.  Provider Number 
       
| X |  X |  0 |  0 |  0 |  0 | (Hospital) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0| 1| (Hospital)                 4 4                          4 4          
 
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |  
 
EXAMPLE 5:  100 bed nursing home (free-standing) 
 
Beds are distributed as follows: 
60 beds certified for Medicaid 
40 beds not participating in either Medicare or Medicaid 
 
1.  Provider Number 
 
| X |  X |A,E, or F|  0 |  0 |  0 | (NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
        
| 1| 0 |  (NF)                  1 0 0                        6 0           
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |  
                                60 
  EXAMPLE 6:  75 bed Medicaid NF (free-standing) 
 
1.  Provider Number 
 
| X | X  |A, E or F| 0  | 0  | 0  | (Title 19 NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|1 |0 |(NF)                  7 5                          7 5         
 
 
14. 
LTC Certified Bed Breakdown  
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                                75 
 
EXAMPLE 7: 150 bed SNF/NF and NF 
 
Beds are distributed as follows: 
100 beds SNF/NF 
50 NF beds  
 
1.  Provider Number 
 
| X | X  | 5  | 0  | 0  | 0  |  (Title 18 & 19 SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
|0 |3 |(SNF/NF)                1 5 0                      1 5 0          
 
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                  100        50 
  EXAMPLE 8:  100 SNF/NF facility 
 
100 beds - SNF/NF dually participating 
 
NOTE: Blocks A-E within item 14 must not exceed the total number of certified beds 
recorded in item 13.  Report dually-participating beds in block B (18/19 SNF).  Block F is 
no longer applicable. 
 
1.  Provider Number 
  
|  X|  X |  5 |  0 |  0 |  0 |  (18/19 SNF/NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 0| 2| (SNF/NF               1 0 0                         1 0 0        
         Dually- 
         Participating) 
 
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
 
                  100 
  EXAMPLE #9:  125 bed SNF/NF facility 
 
Beds are distributed as follows: 
100 beds - Title 19 NF  
25 beds -   Title 18/19 SNF/NF DP 
See Example #8 Note. 
 
1.  Provider Number 
  
| X |  X |  5 |  0 |  0 |  0 |  (18/19 SNF/NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
        
| 0 | 3|(SNF/NF)              1 2 5                       1 2 5         
 
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                   25        100 
 
EXAMPLE 10:  150 bed Medicaid-only NF 
 
Beds are distributed as follows: 
125 beds - Title 19 NF 
25 beds - not participating in Medicare or Medicaid 
 
1.  Provider Number 
  
| X |  X |A, E, or F |  0 |  0 |  0 |  (Title 19 NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1 | 0| (NF)                 1 5 0                         1 2 5        
 
 
14. 
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |  
                               125                             EXAMPLE 11:  140 bed NF (free-standing) 
 
1.  Provider Number 
  
| X | X  |A, E or F | 0  | 0  | 0  |  (NF) 
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1| 0| (NF)                 1 4 0                        1 4 0        
 
 
14.  
LTC Certified Bed Breakdown    
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                              140                   | 
 
EXAMPLE #12 - 30 bed ICF/IID (free-standing) 
 
1.  Provider Number 
 
| X |  X |  G |  0 |  0 |  0 |  (ICF/IID)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1| 1| (IMR)                  3 0                          3 0          
 
 
14.  
LTC Certified Bed Breakdown   
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                                                30                          | 
  EXAMPLE #13 - 50 bed NF and ICF/IID facility 
 
Beds are distributed as follows: 
30 beds - Title 19 NF 
20 beds - Title 19 ICF/IID 
 
NOTE:  Prepare two Forms CMS-1539 identifying the NF and ICF/IID components. 
 
1.  Provider Number 
 
| X |  X |A,E,or F |  0 |  0 |  0 |  (NF)  
 
7.              12.                13. 
CATEGORY        TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1|0 | (NF)                 3 0                          3 0          
 
 
14. 
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID   |   
                                30        
 
1.  Provider Number 
  
| X |  X |  G |  0 |  0 |  0 |  (IMR)  
 
7.            12.               13. 
CATEGORY      TOTAL FACILITY BEDS  TOTAL CERTIFIED BEDS 
       
| 1| 1| (ICF/IID)                2 0                           2 0           
 
 
14. 
LTC Certified Bed Breakdown 
 
| SNF   | SNF/NF  |  NF   |   ICF/IID  |   
                                                20 
  Item 17 - Surveyor Signature 
 
The surveyor (or survey team leader) signs and dates Form CMS-1539 after ensuring that 
the certification documents are complete and accurate. 
 
Item 18 - State Agency Approval 
 
The authorized representative of the SA signs and dates Form CMS-1539 and forwards the 
certification material to the RO or SMA, as appropriate.  His/her signature constitutes for 
Medicare the official certification that the information being reported is correct 
according to official State files.  In Medicaid-only cases, the signature on this document 
represents the adjudicative decision of the SA on the qualifications of the institution to 
participate in the Medicaid program. 
 
2765 - MAC Tie-In Activities 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
The SA maintains a list of the MACs available to serve providers in the area.  The SA 
includes this list in the initial mailing kit sent to new provider candidates.  This list 
contains the MACs names, addresses, telephone numbers, and service areas.  It also 
indicates that MAC elections are subject to approval by the RO and that questions 
regarding MAC selection should be addressed to the RO.  The RO furnishes updated lists 
to the SA when the availability of MAC changes. 
 
2766 - Spell of Illness Supplement, Form CMS-1539A (Exhibit 10) 
(Rev. 1, 05-21-04) 
 
2766A - Form(s) to Use 
(Rev. 1, 05-21-04) 
 
The SA completes both a Form CMS-1539 and a Spell of Illness Supplement, Form CMS-
1539A, in making 1861(e)(1) and 1819(a)(1) (formerly 1861(j)(1)) certifications.  The 
SA forwards the forms to the RO for determination, maintenance of listings, and 
notification to intermediaries and other interested parties. 
 
For convenience, a single Form CMS-1539A may include certifications for all areas of an 
institution when there is more than one part. 
 
Situation - Hospital being approved for participation, contains part rendering non-hospital 
services. 
 
Action - The SA checks Item 14(c) (1 or 2) on Form CMS-1539 and prepares 1819(a)(1) 
certification(s) on Form CMS-1539A.  If Does not meet 1819(a)(1) is checked on 
Form CMS-1539A, add: or (e)(1). 
 
Situation - Hospital being denied or terminated and fails to meet 1861(e)(1) definition; 
entire facility meets (or does not meet) 1819(a)(1) definition.   
Action - The SA checks Item 14(b)(2) and Item 14(c)(1) or (3) on Form CMS-1539 and 
explains in Item 17. 
 
Situation - Hospital fails to meet 1861(e)(1) definition; part of facility meets and part 
does not meet  1819(a)(1) definition. 
 
Action - The SA checks Items 14(b)(1) or (2) and 14(c)(1) and (2) on Form CMS-1539, 
and provides explanation in Item 17.  The SA prepares 1819(a)(1) certification(s) on 
Form CMS-1539A.  If Does not meet 1819(a)(1) is checked, add or (e)(1). 
 
Situation - Hospital not participating and no termination involvement; contains part 
rendering non-hospital services. 
 
Action - The SA prepares 1819(a)(1) certification(s) on Form CMS-1539A.  If Does not 
meet 1819(a)(1) is checked, add or (e)(1). 
 
Situation - Distinct part SNF being approved for participation. 
 
Action - The SA checks Item 14(c)(1) of Form CMS-1539 and prepares Form 
CMS-1539A. 
 
Situation - SNF does not meet one or more Conditions; entire facility meets (or does not 
meet) 1819(a)(1) definition. 
 
Action - The SA checks Item 14(c)(1) and (2) on Form CMS-1539; prepares Form CMS-
1539A. 
 
Situation - SNF does not meet one or more Conditions; part of facility meets and part 
does not meet 1819(a)(1) definition. 
 
Action - The SA checks Item 14(c)(1) and (2) on Form CMS-1539; provides explanation 
in Item 17; prepares Form CMS-1539A. 
 
Situation - Nursing facility with no SNF and no termination involvement. 
 
Action - Prepare Form CMS-1539 and Form CMS-1539A. 
 
2766B - Items on Form CMS-1539A 
(Rev. 1, 05-21-04) 
 
Item 2 - In addition to the name and address of the facility, the SA identifies the part of 
the facility the spell of illness certification refers to; e.g., first and second floors of the 
West Building, or rooms numbered 23-31 of the East Wing of the Tower Building. 
 
Items 3-7 - Self-explanatory. 
  Item 8 - Number of beds, and number of beds occupied.  These items pertain to the 
number of beds within the part of the institution identified in Item 1. 
 
2772 - Packet of Documentation Attached to Certification and 
Transmittal by SA 
(Rev. 1, 05-21-04) 
 
Direct Data Entry instructions identify those packets that must be sent to the RO or SMA 
by the SA. For those packets that must be sent, the SA refers to Exhibit 63 for a complete 
listing of forms and other materials to be sent to the RO or SMA as attachments to Form 
CMS-1539 or Form CMS-1540.  The SA assembles the materials in the order listed in the 
exhibit. 
 
2774 - Routing of Medicaid-only Certifications 
(Rev. 1, 05-21-04) 
 
While Medicaid is a State-administered program, the RO has responsibility for monitoring 
all Medicaid certification actions.  After the SMA takes required actions, it forwards 
appropriate certification materials to the RO as required by the Direct Data Entry program. 
 
The RO reviews the packets for completeness, acceptability of PoC, and appropriateness 
of compliance decisions.  Since the review is post-certification, feedback is provided to 
the SA on a case-by-case basis, as appropriate.  Medicaid provider agreements are subject 
to CMS review.  In the event prescribed forms, regulations, and procedures were not 
followed, CMS could disallow FFP in Medicaid payments to the SMA for the involved 
facilities, i.e., old look behind. 
 
2776 - RO Requests for Additional Information 
(Rev. 1, 05-21-04) 
 
The Regional Office Request for Additional Information or Other Action (Form CMS-
1666) (see Exhibit 15) provides the RO a means of requesting further information or 
additional action from the SA at any stage of processing a certification action or providing 
technical assistance.  The SA uses the reverse side of the form to reply and to summarize 
additional development.  If the RO does not request a specific due date, the SA forwards 
its response (or an interim response) within 20 calendar days of receipt of the request.  The 
SA keeps a copy of Form CMS-1666 in the provider/supplier file for its records. 
 
Form CMS-1666 may be used for a myriad of reasons, such as requesting information or 
providing technical assistance.  It may also be used to request certain actions, such as 
surveys, or to inform States of processing errors.  In preparing Form CMS-1666, the RO 
completes the self-explanatory portions of the form, (e.g., the addressee, facility name, 
and provider number) and provides relevant section numbers in the manuals, if 
appropriate.  The RO may include suggestions for the desired action along with a 
requested response date.  The original is sent to the SA, and a copy is filed inside the 
folder until the completed original is returned. 
  The RO maintains a log or file of requests to the SA for additional information (i.e., Form 
CMS-1666s, letters, documented telephone contact reports) which reflects the date of each 
request, the requested information, the requested response date, and the date the RO 
received the reply. 
 
2777 - RO Review of SA Certifications 
(Rev. 1, 05-21-04) 
 
2777A - Medicaid-Only Certifications 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
With the exception of State-operated NFs, which are certified by CMS, the SA completes 
all Medicaid-only certifications and forwards them to the State Medicaid agency (SMA) 
within 45 days after the survey.  The SMA initiates appropriate action based on the SAs 
certification of the Medicaid-only provider.  After this action is completed, the SMA 
forwards the case (with the exception of Form HHS-441, Assurance of Compliance with 
the Department of Health and Human Services Regulations under Title V of the Civil 
Rights Act of 1964, or a comparable form, which is submitted to the applicable Regional 
Office of Civil Rights) to the SA for entry into the ASPEN system.  Before the initial 
certification is entered into the ASPEN system, the SA assigns a CCN to the NF, hospital 
or ICF/IID.  The ASPEN system screens the facilitys current compliance record for 
Conditions of Participation (CoPs), Requirements (for NFs), and other RO flags. 
 
2777B - State-Operated Medicaid NFs 
(Rev. 1, 05-21-04) 
 
These facilities are certified by the CMS RO. 
 
2777C - Medicare Certifications 
(Rev. 1, 05-21-04) 
 
The SA must certify participating providers and suppliers of services and forward the 
certification to the RO within 45 days after the survey.  The RO reviews all initial SA 
certifications when received.  The SA enters routine recertification cases into the OSCAR 
system.  The OSCAR system screens the facilities current certification compliance 
records for CoPs, Requirements for SNFs, and other RO flags that are out of compliance.  
If there is a deficiency in one or more of these requirements, the OSCAR system may 
notify the SA to forward the case to the RO for additional review.  The SA retains 
unflagged certification documents.  Exhibit 164 is a suggested checklist that the RO 
certification specialist may use as a guide to review certification kits received from the 
SA.  The RO modifies the checklist to suit changing needs or variances. 
 
2777D - Change in Certification 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
2777D1 - Medicaid NF and Medicaid Distinct Part NF Providers Seeking  to Participate as Medicare SNF providers 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
When Medicaid NF and Medicaid distinct part NF providers wish to participate as 
Medicare SNF providers, the SA sends the most recent survey information obtained 
during the latest Medicaid survey along with other documentation required for an initial 
Medicare certification of a SNF (Exhibit 63) to the RO for official determination of 
whether to approve the facility and enter into a provider agreement.  If these documents 
provide adequate evidence that the facility is in compliance with the requirements 
governing program participation, the RO notifies the provider of the effective date of 
Medicare participation.  The effective date is the date requested by the provider, but 
cannot be earlier than the date the request is filed with the RO or the SA. 
 
The requesting facility must sign a Medicare provider agreement, which will be in effect 
concurrently with its present Medicaid agreement.  The facility will be surveyed for both 
programs at the end of the current period of Medicaid certification.  
 
A facility may increase its Medicare distinct part by converting Medicaid NF beds to 
Medicaid/Medicare SNF/NF beds without a survey.  In expanding a distinct part, 
providers must adhere to distinct part organizational requirements and accounting 
principles. 
 
2777D2  Medicare- and Medicaid-Participating Hospitals Seeking to 
Become Medicaid-Only Hospitals 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
When a hospital that dually participates in Medicare and Medicaid wishes to voluntarily 
terminate its Medicare provider agreement, but continue to participate in Medicaid only, it 
must provide written notification to the SA and submit a completed Form CMS-855A to 
the MAC as required in Chapter 15, Section 10 of the Program Integrity Manual, 
Publication 100-08.  In terms of survey and certification, voluntary terminations of the 
Medicare provider agreement will be processed in accordance with SOM Section 3046.  A 
Non-deemed hospital will be surveyed at the time it ordinarily would have been subject to 
a recertification survey had it continued to participate in Medicare.  In the case of a 
deemed hospital, it will be surveyed by its CMS-approved AO when its current 
accreditation is due for renewal. 
 
2777D3 - Medicaid-Only Hospitals Seeking to Participate in Medicare 
and Medicaid 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
When a Medicaid-only hospital wishes to participate in both Medicare and Medicaid, it 
must submit a Form CMS-855A to the MAC. After receipt of the MACs recommendation 
to approve the hospitals enrollment in Medicare, the SA sends the survey findings from 
the most recent Medicaid survey and its certification of Medicare CoP compliance or 
noncompliance based on that survey, along with other documentation required for an 
initial Medicare certification (see Exhibit 63), to the RO.  The RO determines whether or  not to approve the hospital for Medicare participation and enter into a provider agreement. 
 
In the case of a Medicaid-only deemed hospital, after receipt of the MACs 
recommendation for approval, the hospital must notify its CMS-approved AO of its 
application to change its status from a Medicaid-only hospital to a Medicare- and 
Medicaid (dually)participating hospital.  The hospital must request the AO to send the 
most recent survey report to the RO.  The RO determines whether or not to approve the 
hospital for Medicare participation and enter into a provider agreement. 
 
The RO has the option of requiring a new full, standard survey if it has concerns based on 
the most recent Medicaid survey findings.   
 
  If the RO determines there is substantial compliance with Medicare participation 
requirements based on the most recent Medicaid survey, it determines the effective 
date in accordance with 42 CFR 489.13, retires the previously issued Medicaid-only 
hospital CCN number and  issues a Medicare CCN along with the signed Medicare 
provider agreement.  The Medicare participation effective date may be the date 
requested by the provider, but cannot be earlier than the date the CMS 855A was 
approved by the Medicare Administrative Contractor (MAC) or, if there are other 
applicable federal requirements, the date on which all federal requirements were met. 
See Section 2780 concerning the effective date of the Medicare agreement. 
 
The Medicare provider agreement is in effect concurrently with the Medicaid 
agreement.  The facility will be surveyed for both programs at the end of the current 
period of Medicaid certification.   In the case of Medicaid-only deemed hospitals, 
when the AO surveys the hospital when the accreditation is due for renewal, it follows 
the standard process for notifying CMS of accreditation and recommendation of 
continued Medicare deemed status. 
 
  If the RO requires a new full, standard survey and that survey indicates substantial 
compliance, the RO determines the effective date in accordance with 42 CFR 489.13.  
The Medicare participation effective date cannot be earlier than the date the survey 
was completed or, if applicable, the date an acceptable plan of correction was received.  
See Section 2780 concerning the effective date of the Medicare agreement. 
 
If the survey indicates noncompliance, the RO denies the hospitals Medicare certification 
application.  See Section 2005A2 for the process related to a denial.  The SA must also 
advise the State Medicaid Agency of the substantial noncompliance. 
 
2778 - Objectives of RO Certification Review 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The primary objective of the review is to assure that the certification, together with other 
documents, is adequate evidence of the identity of the certified institution and of its 
conformance to the laws and regulations governing program participation. 
 
Since the RO certification specialist must process various request forms and notifications  and assure that the documentation is complete, it is of paramount importance that the 
specialist perform a quality-oriented appraisal. 
 
Before approving participation, the RO must be certain that the SAs certification of 
compliance is consistent with the documented findings.  The RO considers the impact of 
deficient standards, elements, or Requirements (for SNFs and NFs) on the respective CoPs 
or Requirements; the providers deficiency history profile; recent beneficiary complaints; 
or other external reports justifying further documentation of a providers practices and 
consults with RO health professionals when appropriate. 
 
Other objectives are accomplished by this review.  The RO decides whether it agrees with 
the SA recommendation of compliance or noncompliance and its interpretation of 
reasonable time and reasonable plans for the correction of deficiencies and waivers.  The 
RO reviews the Statement of Deficiencies and Plan of Correction, Form CMS-2567, to 
ensure that the SAs documentation supports the SA certification recommendation, 
acceptable plan of correction (PoC), or waiver request.  The RO notes the timeliness and 
quality of SA processing, and extract information relating to administrative or program 
problems that the case reveals so that identified program problems can be corrected on the 
regional or national level. 
 
In the case of hospitals that participate in both Medicare and Medicaid or Medicaid-only 
or of Critical Access Hospitals (CAHs), the RO must ensure the completion of the 
Hospital/CAH database worksheet (Exhibit 286) by the SA for all certifications, including 
initial certifications, regardless of whether the survey was conducted by the SA or AO.  
The survey kit will not upload without completion in ASPEN of the worksheet. 
 
In Medicaid-only cases, the SA certifies its determination as to the providers compliance 
with the participation requirements.  With the exception of PRTFs, the SMA must accept 
certification determinations as final and may not enter into a provider agreement with a 
NF, HHA, hospital or ICF/IID unless the SA has certified the provider as in compliance 
with applicable requirements for program participation.  It may, however, for good cause, 
refuse to execute an agreement with a NF, HHA, hospital or ICF/IID certified by the SA.  
(See 42 CFR 442.12(d).) 
 
Certification documents are official statements of the SA that may not to be altered.  
The RO uses the Request for Additional Information, Form CMS-1666 (Exhibit 15), to 
request additional information or documentation.  (See 2776.) 
 
If a deficiency is subsequently corrected, the corrective action will be shown on Form 
CMS-2567 or the Post-Certification Revisit Report, Form CMS-2567B, as appropriate.  If 
the deficiencies have not been corrected at the time of the revisit, they are shown on a new 
Form CMS-2567.  The CASPER system accumulates data on the ability of providers and 
suppliers to meet program participation requirements at the time of the survey.  CASPER 
data from Form CMS-2567 and Form CMS-2567B are used to measure the extent of 
progress providers and suppliers make in complying with program requirements. 
 
In case of an unreconciled interpretive disagreement with the SA, the RO can arrive at a  determination disagreeing with the SA, provided there is evidence to support a 
contrary decision.  If the RO disagrees with the SA certification, it justifies its rejection 
in writing and attempts to resolve the disagreement.  If necessary, a disagreement over 
interpretive policy can be referred to CMS CO for resolution. 
 
2779 - RO Assignment of CMS Certification Numbers  
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
2779A - Numbering System for CMS Certification Numbers (CCN) 
(Rev. 152, Issued: 03-25-16, Effective: 04-04-16, Implementation: 04-04-16) 
 
Effective in 2007, the CCN replaced the term Medicare Provider Number, Medicare 
Identification Number or OSCAR Number.  The CCN is used to verify 
Medicare/Medicaid certification for survey and certification, assessment-related activities 
and communications.  Additionally, CMS data systems use the CCN to identify each 
individual provider or supplier that has or currently does participate in Medicare and/or 
Medicaid.  The RO, not the SA or MAC, assigns the CCN and maintains adequate 
controls. 
 
2779A1  CCN for Medicare Providers 
(Rev. 205; Issued: 03-11-22; Effective: 03-11-22; Implementation: 03-11-22) 
 
The CCN for providers and suppliers paid under Medicare Part A have 6 digits.  The first 
2 digits identify the State in which the provider is located.  The last 4 digits identify the 
type of facility. 
 
Following is a list of all State Codes: 
 
Alabama  01  New Hampshire  30 
Alaska  02  New Jersey  31, 83 
Arizona  03, 00  New Mexico  32, 96 
Arkansas  04, 89  New York   33, 57 
California  05, 55, 75, 92,  North Carolina  34, 86 
A0, A1, B2 
Colorado  06, 91  North Dakota  35 
Connecticut  07, 81  Ohio  36, 72, A6 
Delaware  08  Oklahoma  37, 90 
District of Columbia  09  Oregon  38, 93 
Florida  10, 68, 69, A2  Pennsylvania  39, 73, A7 
Georgia  11, 85  Puerto Rico  40, 84 
Hawaii  12  Rhode Island  41 
Idaho  13, 54  South Carolina  42, 87 
Illinois  14, 78  South Dakota  43 
Indiana  15  Tennessee  44, 88, A8 
Iowa  16, 76  Texas  45, 67, 74, 97, 
A9 
Kansas  17, 70  Utah  46  Kentucky  18, B0  Vermont  47 
Louisiana  19, 71, 95, A3  Virgin Islands  48 
Maine  20  Virginia  49 
Maryland  21, 80  Washington  50, 94 
Massachusetts  22, 82  West Virginia  51, 58, B1 
Michigan  23, A4  Wisconsin  52 
Minnesota  24, 77  Wyoming  53 
Mississippi  25, A5  Canada  56 
Missouri  26, 79  Mexico  59 
Montana  27  American Samoa  64 
Nebraska  28  Guam  65 
Nevada  29  Commonwealth of the  66 
Northern Marianas Islands 
    Foreign Countries  99 
(exceptions: Canada and 
Mexico) 
 
New State codes must only be used when all of the existing assigned numbers have been 
assigned within each of the CCN ranges available for a facility type. 
  
Assign the last 4 digits, which identify the facility type, sequentially from within the 
appropriate CCN range.  In a State that has more than one State code and/or a facility type 
that has more than one CCN range available, ensure that all the numbers available in one 
CCN range have been assigned before implementing the use of a new State code or 
numbers in a new CCN range. 
 
For example:  You are assigning a CCN to a new Community Mental Health Center 
(CMHC) in Florida.  Florida has three State Codes:  10, 68 and 69 and three number 
ranges for CMHCs: 1400-1499, 4600-4799, and 4900-4999. You have been using State 
Code 68 and the CCN range 4900-4999 for CMHC in Florida, and you last assigned 4999 
in that State to a CMHC. Given this information, consider the following scenarios:  
 
  Scenario 1.  Review the CCN records for Florida to determine if all the numbers in 
CCN range 4600-4799 were assigned.  It is determined that all those numbers were 
previously assigned in Florida.  Therefore, look to CMHC CCN range 1400-1499 as 
those numbers have not been assigned in Florida; assign 681400 as the CCN for the 
new CMHC that is being processed. 
 
  Scenario 2.  Review the CCN records for Florida to determine if all the numbers in 
CCN range 4600-4799 were previously assigned in Florida.  It is determined that 
some, but not all, of the numbers in that CCN range were assigned.  The last number 
in that range that was assigned was 4701.  Assign 684702 as the CCN for the new 
CMHC that is being processed. 
 
  Scenario 3.  Review the CCN records for Florida to determine if all the numbers in 
CCN range 4600-4799 were previously assigned in Florida.  It is determined that all 
the numbers in that range were previously assigned in Florida.  It is then determined  after a review of the CCN records that all of the numbers in CCN range 1400-1499 
were previously assigned in Florida.  Look to see if all three CMHC CCN ranges for 
State Code 10 have been assigned.  It is determined that all three CCN ranges have 
been previously assigned.  Then look to State Code 69.  You find that no CCN for 
CMHC in Florida has been assigned under State Code 69.  The new CCN that will be 
assigned to the new Florida CMHC will be 691400 because is the first CCN range 
under State Code 69 listed for CMHCs.  However, if it is determined that one of the 
CMHC CCN ranges under State Code 69 has been previously assigned, begin with the 
next available number in that CCN range. 
 
NOTE: Once the remaining pool of two digit State numeric codes are exhausted, CMS 
will implement a two digit alpha-numeric code system for State Codes.  For example:  
A0, A1, A2,... B0, B1, B2,..., Z8, and finally Z9).  This numbering system will 
provide a pool of 260 new State Codes for future use. 
 
Use the following CCN ranges for the facility types indicated: 
 
0001-0879  Short-term (General and Specialty) Hospitals 
0880-0899  Reserved for hospitals participating in ORD demonstration project 
0900-0999  Multiple Hospital Component in a Medical Complex (Numbers Retired) 
1000-1199  Federally Qualified Health Centers (also CCN range 1800-1989) 
1200-1224  Alcohol/Drug Hospitals (Numbers Retired) 
1225-1299  Medical Assistance Facilities 
1300-1399  Critical Access Hospitals 
1400-1499  Continuation of Community Mental Health Centers (also CCN ranges 
4600-4799 and 4900-4999) 
1500-1799  Hospices 
1800-1989  Federally Qualified Health Centers (also CCN range 1000-1199) 
1990-1999  Religious Non-medical Health Care Institutions (formerly Christian 
Science Sanatoria (Hospital Services) 
2000-2299  Long-Term Care Hospitals (Excluded from IPPS)  
2300-2499  Hospital-based Renal Dialysis Facilities 
2500-2899  Independent Renal Dialysis Facilities 
2900-2999  Independent Special Purpose Renal Dialysis Facility 1/ 
3000-3024  Formerly Tuberculosis Hospitals (Numbers Retired) 
3025-3099  Rehabilitation Hospitals (Excluded from IPPS) 
3100-3199  Home Health Agencies (also CCN ranges 7000-8499 and 9000-9799) 
3200-3299  Continuation of Comprehensive Outpatient Rehabilitation Facilities  (also CCN ranges 4500-4599 and 4800-4899)  
3300-3399  Childrens Hospitals (Excluded from IPPS) 
3400-3499  Continuation of Rural Health Clinics (Provider-based) (also CCN 
ranges 3975-3999 and 8500-8899)  
3500-3699  Hospital-based Satellite Renal Dialysis Facilities 
3700-3799  Hospital-based Special Purpose Renal Dialysis Facility 1/ 
3800-3974  Rural Health Clinics (Free-standing) (also CCN range 8900-8999) 
3975-3999  Rural Health Clinics (Provider-based) (also CCN ranges 3400-3499 and 
8500-8899) 
4000-4499  Psychiatric Hospitals (Excluded from IPPS) 
4500-4599  Comprehensive Outpatient Rehabilitation Facilities (also CCN ranges 
3200-3299 and 4800-4899) 
4600-4799  Community Mental Health Centers (also CCN ranges 1400-1499 and 
4900-4999) 
4800-4899  Continuation of Comprehensive Outpatient Rehabilitation Facilities  
(also CCN ranges 3200-3299 and 4500-4599) 
4900-4999  Continuation of Community Mental Health Centers (also CCN ranges 
1400-1499 and 4600-4799)  
5000-6499  Skilled Nursing Facilities  
6500-6989  Outpatient Physical Therapy Services 
6990-6999  Numbers Reserved (formerly Christian Science Sanatoria (Skilled 
Nursing Services) 
7000-8499  Continuation of Home Health Agencies (also CCN ranges 3100-3199 
and 9000-9799)  
8500-8899  Continuation of Rural Health Clinics (Provider-based) (also CCN 
ranges 3400-3499 and 3975-3999)  
8900-8999  Continuation of Rural Health Clinics (Free-standing) (also CCN range 
3800-3974)  
9000-9799  Continuation of Home Health Agencies (also CCN ranges 3100-3199 
and 7000-8499)  
9800-9899  Transplant Centers 
9900-9999  Reserved for Future Use 
1/  Special Purpose Renal Dialysis Facilities (SPRDFs  these facilities will 
be assigned the same CCN whenever they are recertified) 
 
NOTE:  Religious Nonmedical Health Care Institutions (RNHCI) are not certified by 
SAs.  The CCN for RNHCIs are assigned by the Boston CMS RO. 
 
EXCEPTION - Organ procurement organizations (OPOs) are assigned a 6-digit 
alphanumeric CCN.  The first 2 digits identify the State Code.  The third digit is the alpha 
character P.  The remaining 3 digits are the unique facility identifier. 
  EXCEPTION- As of the cost reporting period beginning on or after October 1, 2019, an 
IPPS-excluded hospital is no longer precluded from having an IPPS-excluded psychiatric 
and/or rehabilitation unit.  See section 2779C and 2779C1 for additional CCN numbering 
detail. Note:  An IPPS-excluded hospital may not have an IPPS-excluded unit of the same 
type (psychiatric or rehabilitation) as the hospital (for example, an Inpatient Rehabilitation 
Facility (IRF) may not have an IRF unit). 
 
 
 
 
2779A2  CCN for Suppliers 
(Rev. 198, Issued: 01-17-20, Effective: 01-17-20, Implementation: 01-17-20) 
 
Suppliers that are paid by Part B carriers have a 10-digit alphanumeric CCN.  The first 2 
digits identify the State in which the supplier is located.  (See list of State Codes under 
subsection 2779A1.)  The third digit is an alpha character that identifies the type of 
facility.  The remaining 7 digits are the unique facility identifier.   (Exception:  CLIA 
numbers will continue to be used for fee and certificate issuance.) 
 
The RO assigns the following alpha-characters in the third position as indicated: 
 
C - Ambulatory Surgical Centers 
D - Clinical Laboratory Improvement Amendments of 1988 (CLIA) Laboratories 
X - Portable X-Ray Facilities 
(Exception:  CLIA numbers are system generated by the database that maintains the 
CLIA application.) 
 
The last 7 digits of the CCN for the above suppliers will be within the number series 
0000001-9999999. 
 
Examples: 
 
ASC   10C0001062 
CLIA   45D0634589 
Portable X-Ray   21X0009807 
 
2779B  CMS Certification Numbers for Medicaid Providers 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
For certification purposes, title XIX-only providers are identified by a 6-digit 
alphanumeric CCN.  The first 2 digits identify the State in which the provider is located. 
The third position, which is an alpha character, identifies the type of facility by level or 
type of care being provided.  The last 3 digits make up a sequential number series 
beginning with 001. 
 
The RO uses the following groups of alphanumeric numbers for the type of facility as 
indicated:  A001-A999  NF (Formerly assigned to Medicaid SNF) 
B001-B999  NF (Formerly assigned to Medicaid SNF) 
                     Expansion of A001-A999 
E001-E999  NF (Formerly assigned to ICF) 
F001-F999  NF (Formerly assigned to ICF) 
                     Expansion of E001-E999 
G001-G999  ICF/IID 
H001-H999  ICF/IID 
                     Expansion of G001-G999 
K001-K999             Medicaid HHAs 
L001-L999  Psychiatric Residential Treatment Facilities (PRTF) 
J001-J099  Medicaid-Only Short-term acute care hospitals  
J100-J199  Medicaid-Only Childrens Hospitals 
J200-J299  Medicaid-Only Childrens Psychiatric Hospitals 
J300-J399  Medicaid-Only Psychiatric Hospitals 
J400-J499  Medicaid-Only Rehabilitation Hospitals 
J500-J599  Medicaid-Only Long-term Hospitals 
J600-J999  Reserved for future use 
 
2779C - Special Numbering System for Units of Hospitals That Are 
Excluded From the Inpatient Prospective Payment System (IPPS) and 
Hospitals and CAHs with Swing-Bed Approval 
(Rev. 198, Issued: 01-17-20, Effective: 01-17-20, Implementation: 01-17-20) 
 
An alpha character in the third position of a hospitals or CAHs CCN identifies either its 
swing-bed approval or its status as an IPPS-excluded rehabilitation or psychiatric unit. The 
first 2 digits identify the State in which the provider is located.  The third position (which 
is alpha) identifies the type of unit or swing-bed designation.  The last 3 digits must be 
exactly the same as the last 3 digits of the CCN of the hospital or CAH operating the 
unit(s), unless as noted below in Section 2779C1.   
NOTE: As of the cost reporting period beginning on or after October 1, 2019, an IPPS-
excluded hospital is no longer precluded from having an IPPS-excluded psychiatric and/or 
rehabilitation unit (see Section 2779C1 for CCN numbering).  
The RO assigns the following alpha-characters in the third position as indicated: 
M - Psychiatric Unit of a CAH 
R - Rehabilitation Unit of a CAH 
S - Psychiatric Unit of a Short-Term, Cancer, Childrens, LTCH, or  Rehabilitation Hospital 
T - Rehabilitation Unit of a Short-Term, Cancer, Childrens, LTCH, or 
Psychiatric Hospital 
U - Swing-Bed Approval for Short-Term Hospitals 
W- Swing-Bed Approval for Long-Term Care Hospitals 
Z - Swing-Bed Approval for CAHs 
 
EXAMPLE:  21-0101 - ABC Hospital (Short-Term Hospital) 
 
  21-T101 - ABC Hospitals IPPS-excluded Rehabilitation Unit 
 
  21-S101  ABC Hospitals IPPS-excluded Psychiatric Unit 
 
  21-U101- ABC Hospitals Swing-bed Approval 
 
  NOTE: If it meets the applicable requirements, an acute care hospital 
or a CAH could have swing-bed approval, an IPPS-excluded 
rehabilitation unit, and/ or an IPPS-excluded psychiatric unit. 
 
 
2779C1- Special Numbering System for IPPS-Excluded Hospitals with 
IPPS-Excluded Units  
(Rev. 198, Issued: 01-17-20, Effective: 01-17-20, Implementation: 01-17-20) 
 
If an IPPS-excluded hospital also has an IPPS-excluded unit, the fourth position within the 
CCN requires an additional alpha-character to identify the IPPS-excluded unit type. Note: 
No special fourth position alpha character is needed for cancer hospitals.  
 
The RO assigns the following alpha-characters in the fourth position as indicated in the 
table below.  Note: This table does not apply to CAHs. 
 
Parent IPPS-Excluded Hospital  Psychiatric Unit Range  Rehab Unit Range 
 
LTCH XX-2000 through XX-2299     
XX-2000  through XX- XX-SA00 through XX- XX-TA00 through XX-
2099  SA99  TA99 
XX-2100  through XX- XX-SB00 through XX- XX-TB00 through XX-
2199  SB99  TB99 
XX-2200  through XX- XX-SC00 through XX- XX-TC00 through XX-
2299  SC99  TC99 
     
Rehabilitation Hospital XX-3025  XX-SD00 through XX- Not Applicable 
through XX-3099  SD99 
     
Childrens Hospital XX-3300  XX-SE00 through XX- XX-TE00 through XX-
through XX-3399  SC99  TE99 
      Psychiatric Hospital XX-4000  Not Applicable   
through XX-4499 
XX-4000  through XX-   XX-TF00 through XX-
4099  TF99 
XX-4100  through XX-   XX-TG00 through XX-
4199  TG99 
XX-4200  through XX-   XX-TH00 through XX-
4299  TH99 
XX-4300  through XX-   XX-TJ00 through XX-
4399  TJ99 
XX-4400  through XX-   XX-TK00 through XX-
4499  TK99 
 
NOTE: An IPPS-excluded hospital may not have an IPPS-excluded unit of the same type 
(psychiatric or rehabilitation) as the hospital (for example, an Inpatient Rehabilitation 
Facility (IRF) may not have an IRF unit). 
 
EXAMPLE:    21-2026 - XYZ Hospital (IPPS-excluded Long Term Care Hospital) 
  21-SA26 - XYZ Long Term Care Hospitals IPPS-excluded Psychiatric 
Unit 
  21-TA26  XYZ Long Term Care Hospitals IPPS-excluded 
Rehabilitation Unit 
 
2779D - Assigning LTC CMS Certification Numbers 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
The RO assigns only one CCN per facility.  (For purposes of this section, facility means 
an institution providing SNF and/or NF or ICF/IID care at the same address.)  Use XX-
5000 series for facilities providing Medicare or Medicare/Medicaid services, and the 
alphanumeric series (XX-A000 or XX-E000 or XX-G000) for Medicaid-only facilities, as 
shown in the following charts: 
 
 
FREE STANDING LTC FACILITIES 
 
 
FACILITY    18 or 18/19    19 NF       ICF/IID 
TYPE                SNF  
 
 
CCN         XX-5000    XX-A000 or      XX-G000       
                    XX-E000  
 
  SNF/NF DUALLY-PARTICIPATING AND/OR DISTINCT PART FACILITIES 
 
 
FACILITY    18/19       18 SNF or 18/19    18 or 18/19   
TYPE       SNF/NF    Dually participating    Dually participating  
Dually     with SNF or NF DP    with SNF or NF DP 
participating  
 
CCN         XX-5000    XX-5000      XX-5000 
 
 
FACILITY TYPE         19 NF       19 NF 
With 
ICF/IID DP 
 
CCN                   XX-A000      XX-A000 or 
XX-E000 or 
XX-G000* 
 
*EXCEPTION:  As the chart indicates, the RO always assigns a separate ICF/IID (XX- 
            G000) number to an ICF/IID or ICF/IID DP. 
 
NOTE:  When a LTC facility is a unit of a hospital, the RO issues a number separate 
from the hospital number according to the above guidelines.  A hospital is 
permitted to have only one hospital-based SNF DP and one hospital-based NF 
DP. 
 
2779E - Assigning Emergency Hospital CMS Certification Numbers 
(Non-Participating Hospitals) 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
The CCN for emergency hospitals is a 6-position alphanumeric code. The first 2 digits are 
the State code.  The third, fourth, and fifth digits represent a sequence number.  The first 
emergency number in a State would contain the sequence number 001.  In the sixth 
position use the letter E for non-Federal emergency hospitals, or F for Federal 
emergency hospitals.  For example, the 34th emergency hospital issued a CCN in 
Maryland would have the number 21-034E.  The RO assigns the CCN in strict 
numerical sequence without regard to the Federal or non-Federal status.  If a terminated 
facility again qualifies as an emergency hospital, the RO issues a new CCN.  For a non-
participating hospital that is now fully participating, see subsection I. 
 
2779F - Merger of Facilities or CHOW 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
The RO does not change the CCN merely because the institution has been sold, or has 
changed ownership or its form of business organization.  If 2 or more pre-existing 
provider enterprises have merged, but continue to operate as separate facilities, each will  have a separate provider agreement and will keep its original number.  This is true even 
though the merged-but-separate facilities may adopt a common name. 
 
However, if the merged facilities operate as a single institution, it must submit a single 
cost report, which necessitates a single provider agreement/CCN. 
 
When the RO assigns a single CCN, the notices of utilization mailed to beneficiaries will 
not identify which component rendered the service but will show the name of the 
organization to which the CCN is assigned (which may be entirely different from the 
name of the component).  To avoid misunderstanding on the part of beneficiaries, CMS 
must approve, in advance, some method devised by the provider for informing its 
Medicare patients as to the designation on the notices of utilization.  The RO uses the 
CCN previously assigned to the larger of the merging facilities or, in the case of the 
merger of 2 provider corporations, uses the CCN of the surviving corporation and retires 
the other number or numbers. 
 
These principles also apply if providers merge with previous non-providers.   In a merger 
of corporations where the non-provider corporation is the surviving corporation and the 
facilities will use a common number, retain the original number. 
 
This rule does not, however, preclude retention of a separate number for a distinct part 
SNF, or for a distinct part of a psychiatric hospital. 
 
2779G - Notification of Change in CMS Certification Numbers 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
To notify the intermediary of a correction of a CCN, or the assignment of any number 
different from that initially sent to a hospital, the RO prepares a CMS-2007.  Follow the 
procedure in 2783 noting in Item V of CMS-2007 the reason for the number change. 
 
2779H - Retirement of CMS Certification Numbers 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
The CCN will be classified as retired in these situations: 
 
  The provider agreement is terminated; 
 
EXCEPTION:  Where a terminated facility is subsequently reinstated as a 
provider of services fully retroactive to the day of its termination, the RO 
reassigns the original CCN as there has been no break in the period of 
participation. When this occurs, show reinstated with no break in participation, 
in item 24 of Form CMS-1539: 
 
  An erroneous assignment that is used by the facility is subsequently replaced by the 
RO with a correct number; or 
 
  A non-participating hospital or SNF now meets the requirements and wishes to  participate.  The RO assigns a new number and retires the old number. 
 
2779I - Control of CMS Certification Numbers 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
The RO may give responsibility for assigning the CCN to one person, with sufficient 
alternates so that a trained person will always be available. This control may be 
maintained electronically or manually.  The following is a suggested manual control: 
 
Prepare a loose-leaf ledger for the numbers with a tab divider for each State.  Maintain 
separate pages for each type of provider, including non-participating emergency hospitals, 
and make entries in strict numerical sequence. 
 
2779J - ESRD CMS Certification Numbers 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
It is important for both reimbursement and survey purposes to assign the ESRD facility 
the correct CCN in accordance with the guidelines contained in 2779.A.1. 
ESRD facilities and their CCN are as follows: 
 
0001-0879   Short Term (General and Specialty) Hospitals 
2000-2299   Long Term Hospitals 
2300-2499   Chronic Renal Disease Facilities (Hospital-Based) 
2500-2899   Non-Hospital Renal Disease Treatment Centers 
2900-2999   Independent Special Purpose Renal Disease Facilities 
3300-3399   Childrens Hospitals 
3500-3699   Renal Disease Treatment Centers (Hospital Satellites) 
3700-3799   Hospital-Based Special Purpose Renal Dialysis Facilities 
 
1 - Hospital-Based Renal Dialysis Facilities, 2300-2499 
 
The CMS is required to make determinations concerning hospital-based and independent 
ESRD facilities to determine their proper reimbursement in accordance with 1881(b)(7), 
42 CFR 413.174, and 2287.  Please note that in accordance with 42 CFR 413.174(d)(3).  
The physical location of an ESRD facility on the premises of a hospital is not considered 
when determining if the ESRD facility is hospital-based.  In accordance with 42 CFR 
413.174, hospital corporate control is a critical factor in determining whether an ESRD 
facility is hospital-based.  Hospitals may have a lease arrangement for the management of 
a hospital-based ESRD facility by a non-hospital manager. 
 
ESRD CCN 2300-2499, for Hospital-Based Renal Dialysis Facilities are used for ESRD 
facilities that have been determined by the CMS to be hospital-owned, hospital-
administered ESRD facilities physically located on the hospitals premises as opposed to 
independent ESRD facilities and Hospital-Based Renal Disease Satellite Facilities.  The 
satellites are hospital-based, but are physically located off the hospitals premises. 
 
2 - Hospital-Based Renal Dialysis Satellite Facilities, 3500-3699   
ESRD CCN 3500-3699 for Hospital-Based Renal Dialysis Satellite Facilities are used for 
those ESRD facilities that are hospital-owned and hospital administered, but that are not 
located on the hospitals premises.  This is why they are referred to as hospital-based 
satellites.  In determining whether such a satellite facility is hospital-based, use the same 
criteria as you would in making a hospital-based determination under the 2300-2499 
series, except that you would assign a 3500-3699 number to such a facility because it is 
off the premises of the hospital to which it is based.  The word premises per se is not 
defined in the statute, regulations, or in the SOM, but there is a definition of furnishes on 
the premises at 42 CFR 405.2102 that states the ESRD facility furnishes services on its 
main premises; or its other premises that are: (a) contiguous with or in immediate 
proximity to the main premises, and under the direction of the same professional staff and 
governing body as the main premises, or (b) approved on a time-limited basis as a special 
purpose renal dialysis facility.  Thus, in addition to the regulations, which should assist 
you in determining whether the facility is an integral part of the hospital, you may use the 
furnishes on the premises definition to distinguish between a hospital-based entity under 
the 2300-2499 series as opposed to an entity under the 3500-3699 number series.  Also, 
we do not believe that these satellites will be furnishing inpatient dialysis services.  The 
CMS will make or approve the determination that a particular ESRD facility meets the 
requirements to be hospital-based, and if it is off the hospitals premises, a hospital-based 
satellite. 
 
It is conceivable that a hospital-based ESRD facility could have a 2300-2499 number 
assigned to the location on the hospitals premises, and one or more 3500-3699 numbers 
for those locations (satellites) off the premises (each satellite is given a separate 3500-
3699 number).  If an ESRD facility that is assigned a 2300-2499 number moves off the 
hospitals premises and is determined to be a satellite, it should receive a number in the 
3500-3699 series.  However, if a satellite changes its address but is still considered off the 
hospitals premises, it should retain the 3500-3699 number it was originally issued rather 
than being issued a new 3500-3699 number.  Any questions concerning billing should be 
referred to the RO financial component or the fiscal intermediary as you determine 
appropriate. 
 
NOTE:  In determining whether an entity is hospital-based for reimbursement 
purposes, the requirements at 2287 must be met. 
 
3 - Hospital-Based Special Purpose Renal Dialysis Facilities, 3700-3799 
 
In order to be classified as a Hospital-Based Special Purpose Renal Dialysis Facility and 
issued a number under the 3700-3799 series, an ESRD facility must be determined to be 
hospital-based, and meet the definition at 42 CFR 405.2102, and the requirements at 
42 CFR 405.2164 for such a facility.  A facility under this category should bill Medicare 
under the CCN of the hospital to which it is based.  There should be very few of these 
facilities. 
 
4 - Independent Renal Dialysis Facilities, 2500-2899 
  Independent Renal Dialysis Facilities, issued a number under the 2500-2899 series, are 
independent ESRD facilities.  These facilities do not meet the definition of hospital-based 
irrespective of whether they are located on or off the hospitals premises.  A determination 
of independent, as opposed to hospital-based, will be based on the statutory and regulatory 
provisions and manual instructions.  Independent facilities bill under their own numbers.  
ESRD facilities located at skilled nursing facilities will be determined to be independent. 
 
5 - Independent Special Purpose Renal Dialysis Facilities, 2900-2999 
 
The same requirements that apply to a Hospital-Based Special Purpose Renal Dialysis 
Facility apply to a facility of the same type which is independent except that the 
independent facility by virtue of its independent status, bills under its own number which 
is in the 2900-2999 series. 
 
6 - Other 
 
When an ESRD facility proposes to change from hospital-based to independent or vice-
versa, an onsite survey is not necessary unless there is a physical relocation of the facility.  
However, a determination as to the proper facility definition and if necessary, the 
changing of the number designation, must be made in accordance with the guidance 
described here and in 2287.  If an ESRD facility proposes to add a location that has not 
been previously surveyed, an onsite inspection would be required.  In the absence of an 
onsite survey and certification, the proposed facility has no authority to bill Medicare for 
ESRD services provided at the proposed site.  (See 3222.)  There are some instances 
when an ESRD facilitys CCN requires a change as a result of an action taken by the 
ESRD facility.  If a hospital-based facility converts to an independent ESRD facility or if 
an independent ESRD facility converts to a hospital-based ESRD facility, there must be a 
CCN change.  Satellite ESRD facilities must be hospital owned and are considered 
hospital-based.  A hospital may have more than one ESRD satellite facility. 
 
The CCN of the ESRD facility may remain the same in the following situations: 
 
  A hospital-based ESRD facility retains ownership of the facility but contracts 
with another entity for management of the facility; 
 
  The hospital closes the dialysis facility but retains its transplant program.  The 
CMS terminates the outpatient dialysis services but retains the ESRD CCN for 
the still active transplant program; 
 
  The hospital closes the transplant program but retains the ESRD facility.  In 
such case, CMS terminates the transplant program but keeps the ESRD CCN 
active for the dialysis program; 
 
  The ESRD facility is purchased by another ESRD facility of the same type.  
For example, independent by independent or hospital-based by hospital-based; 
and 
    The geographic location of the ESRD facility is changed within the same state.  
A recertification survey is always required when a dialysis facility relocates 
within a state.  If a geographic location is changed to another state, the ESRD 
facility at the old location must be terminated and the relocated ESRD facility 
must qualify as a new applicant with a new identification number in the state to 
which it moved. 
 
Information contained in Medicare approval letters of ESRD facilities that are issued 
numbers under the above categories is essential in central office for data collection and 
program information purposes.  Therefore, please send a copy of all Medicare approval 
letters issued in your region to: 
 
Centers for Medicare & Medicaid Services 
Office of Clinical Standards and Quality 
Information Systems Group 
7500 Security Boulevard 
Mail Stop S3-02-01 
Baltimore, Maryland 21244-1850.   
 
You should also send to the Office of Clinical Standards and Quality (OCSQ) notices of 
any numbers that are terminated or changed (e.g., hospital-based to independent or vice-
versa) for whatever reasons.  In addition, it would be helpful if all ESRD facility notices, 
including those sent to the fiscal intermediary, contain the CCN of the ESRD facility to 
which the notice applies (numbers of both the ESRD facility and the hospital to which it is 
based, when applicable).  You should apprise the appropriate ESRD network of the 
information mentioned above at the same time that you notify OCSQ.  A Form CMS-
855A must be completed by the ESRD facility when there is a change, addition, or 
deletion affecting an ESRD facility.  You should follow the instructions for issuing a 
Provider Tie-In Notice, Form CMS-2000, when an ESRD facility is being added, 
deleted, or changed.  This is particularly important because fiscal intermediaries often 
cross regional boundaries. 
 
NOTE:  The RO refers all Forms CMS-1539 that report changes in provider status 
to its data entry section for input into the ASPEN data system. 
 
When ROs send correspondence concerning certification to ESRD facilities, the following 
information should always appear: 
 
  The assigned CCN with caption; 
 
  CMS cross reference CCN with caption (if applicable); 
 
  Medicare approval date; 
 
  Number of stations; 
 
  Services offered;   
  Name of facility; 
 
  Facilitys physical location address; 
 
  Facilitys mailing address; 
 
  Facilitys type or status (hospital-based/independent/satellite); 
 
  Facility contact for ESRD network; 
 
  Facility ownership (corporation/partnership/sole proprietorship/etc.; and 
 
  RO contact (name and phone number). 
 
EXAMPLE 
 
Maryland 
Short-Term Hospitals 
 
CCN  Name and Address of  Date # Assigned 
Provider 
     
21-0001  Calvert Hospital  4/10/66 
101 Chase Street 
Baltimore, Maryland 
     
21-0002  Red River Hospital  4/11/66 
401 River Road 
Baltimore, Maryland 
 
2779K  HHA Branch CMS Certification Numbers  
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
HHA Branches are identified by the assignment of a 10-digit alpha-numeric number.  Each 
branch is numbered with the same CCN as the parent or subunit with 2 modifications: (1) 
The letter Q will be in the third position between the state code and the 4-digit provider 
designation; and (2) three additional digits are added to the end of the number. The last 3 
digits are a one-up number for each consecutive branch.  These digits allow the capability 
of assigning up to 999 branches to one parent or subunit HHA.  The branch CCN will be 
used only once.  In the event that an HHA branch closes, its unique branch CCN is 
terminated and will not be reused to identify another branch of that HHA or subunit.   
 
Example:  ABC Home Health Agency has three branches.  Its CCN is 017001.  ABCs three 
branches would be assigned the numbers 01Q7001001, 01Q7001002, and 01Q7001003. 
 
2779L  Outpatient Physical Therapy (OPT) Extension CMS  Certification Numbers 
(Rev. 29, Issued:  04-20-07; Effective/Implementation Dates:  10-01-2007) 
 
OPT extensions are identified by the assignment of a 10-digit alpha-numeric number. 
 
Each extension is numbered with the same CCN as the parent with two modifications: (1) 
The letter P will be in the third position between the state code and the 4-digit provider 
designation; and (2) three additional digits are added to the end of the number. The last 3 
digits are a one-up sequence number for each extension number starting with 001. These 
digits allow the capability of assigning up to 999 extensions to one OPT.  The extension 
CCN will be used only once.  In the event that an OPT extension closes, its unique extension 
identification number is terminated and will not be reused to identify another extension of 
that OPT. 
 
OPT extension CCN are not used for reimbursement purposes. 
 
Example:  Vibrant Physical Therapy has three extensions.  Its CCN is 556599.  Vibrants 
three extensions would be assigned the numbers 55P6599001, 55P6599002, and 
55P6599003. 
 
2780 - Effective Date of Provider Agreement, Form CMS-1561, and 
Supplier Approval 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The effective date of participation in the Medicare program, i.e., of the provider agreement 
or supplier approval issued by the RO, may not be earlier than the date on which the 
provider or supplier meets all Federal requirements.  See Section 2008D for discussion of 
Federal requirements.  While the on-site initial certification survey is often the final 
Federal requirement that is met, this is not always the case.  For example, when the 
applicant has not submitted required Office of Civil Rights documentation prior to the 
survey, the determination of compliance with the requirements of the Office of Civil 
Rights may be the final requirement that is met and thus be the effective date of the 
provider agreement or supplier approval.  Another example may be if the MAC 
verification inadvertently occurred after the onsite survey was conducted or, for HHAs, 
when the second MAC review requires additional information for verification of the 
information, then the effective date would be on that date. 
 
2780A - Compliance with All Federal Requirements 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
The agreement is effective on the date the onsite survey is completed if, on the date of the 
survey the entity not only meets all Federal health and safety standards, i.e., the CoPs, 
CfCs or Requirements (for SNFs), but also has met all other applicable Federal 
requirements for Medicare participation. 
 
2780B - All Health and Safety Standards Are Not Met on the Day of the  Survey 
(Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) 
 
If on the initial certification survey the provider or supplier does not meet all applicable 
health and safety standards, then, assuming all other Federal requirements have been met, 
the effective date of the Medicare agreement would be:  
 
  For SNFs, the date the SNF has been found to be in substantial compliance with the 
requirements for participation, and, if applicable, has submitted an approvable waiver 
request. (See 42 CFR 488.301.)  
 
  For non-long term care providers/suppliers, the date when the provider/supplier has: 
 
  Met all applicable conditions, i.e., has no deficiency citations; or 
 
  Has been found to be in substantial compliance, but has standard-level 
deficiencies and the SA or AO has received an acceptable plan of correction 
(POC) and/or CMS receives an approvable waiver request.  If a provider or 
supplier submits both a POC and an approvable waiver request, the later of the 
dates of the two submissions would be the effective date. 
 
  Effective dates of Medicare participation for NFs requesting to participate in the 
Medicare program as SNFs can be any date during the certification period as long as 
the provider is in substantial compliance with all requirements and if applicable, have 
an approved waiver. 
 
  For Medicaid-only facilities, the SA determines whether the PoC is acceptable and 
whether waiver requests for ICFs/IID are approvable.  LSC waivers for Medicaid NFs 
require the ROs approval. 
 
Retroactive SA certifications of compliance with health and safety standards or AO 
accreditation decisions prior to the survey end date are not permitted under any 
circumstances. 
 
2781 - RO Countersigning Provider Agreement 
(Rev. 1, 05-21-04) 
 
After determining that all title XVIII and appropriate civil rights requirements are met, the 
RO signs the Health Insurance Benefits Agreement (Form CMS-1561).  
 
Before countersigning the provider agreement the RO must be certain that the name on 
line 2 of the agreement after the term Social Security Act does, in fact, include both the 
true name of the provider entrepreneur and the trade name of the entity, rather than only 
the trade name. 
 
For example, a partnership of several persons doing business as East Care Home Health 
Services completes the second line of the agreement to read:  Robert Johnson, Louis  Miller, and Paul Allen, ptrs., East Care Home Health Services; the ABC Corporation, 
using the trade name Community General Hospital, completes the agreement to read:  
ABC Corporation d/b/a Community General Hospital.  In the case of sole 
proprietorship, the agreement will read:  John Smith d/b/a Mercy Hospital. 
 
The business name on the agreement should ordinarily conform to the name on all official 
(i.e., IRS) correspondence/forms concerning payroll withholding taxes, such as the SS-4, 
W-3, S-l, or 941 forms.  The instructions on the SS-4 (Application for Employer 
Identification Number) clearly differentiate between the true or entrepreneurial name and 
the trade name.  If a question arises regarding an owners name as it appears on the 
provider agreement, the RO should refer to the above documents. 
 
2782 - RO Notice of Acceptance 
(Rev. 1, 05-21-04) 
 
The RO transmits a letter of acceptance (Exhibit 165) to the provider and encloses a copy 
of the completed Form CMS-1561.  The RO includes in the letter the following notation:  
The (name of intermediary) has been authorized to serve as your fiscal intermediary.  
This is the official notice to the provider of its designated intermediary.  In all acceptance 
notices for hospitals, the RO should state that the agreement applies to the entire hospital, 
or identify the distinct part (including PPS-excluded psychiatric or rehabilitation units 
covered by the agreement) or portions of the hospital covered and not covered in the case 
of a general hospital complex. 
 
In the case of a new hospital the notice must clearly establish the provider numbers which 
apply to each part of the institution.  If a request to establish a PPS-excluded psychiatric or 
rehabilitation unit or swing-bed approval is refused, the RO must be sure that the refusal is 
reflected in the Notice of Acceptance. 
 
The provider number (see 2779) must be imprinted on the agreement, or if more than one 
provider number is assigned, all numbers must be imprinted on the agreement.  The RO 
furnishes the SA and intermediary with a copy of the provider letter.  This will assure that 
the SA and intermediary understand what action has been taken on distinct parts or 
excluded units. 
 
2783 - Provider Tie-In Notice (Form CMS-2007) 
(Rev. 1, 05-21-04) 
 
2783A  Purpose 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
Form CMS-2007 (Exhibit 156) is the official notice to the MAC of changes in its list of 
providers or suppliers (additions, deletions, corrections, recertifications, and terminations). 
 
 
 
2783B - CMS Responsibility for Form CMS-2007 Completion  (Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
The RO completes a Form CMS-2007 each time a provider or supplier is added to or 
deleted from a MACs list of providers and suppliers or when current provider-supplier 
tie-in records require correction and sends it at the time the provider agreement or supplier 
approval is countersigned by its office.  In involuntary termination actions, the RO sends it 
at the same time it issues official notification to the provider or supplier. 
 
2783C - CMS Completion of Form CMS-2007 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
Item I - Identifying Information - This section is self-explanatory.  Complete it in all 
instances. 
 
Item II - New Provider or Supplier Certification - CMS completes this section when a 
new provider or supplier enters the program or when a participating provider or supplier 
has changed ownership.  Items A, C, and D are completed in all cases, and Items E 
through H for changes in ownership.  In item B, CMS shows the month and day of the 
providers or suppliers fiscal year ending date for Medicare cost report purposes (if it 
summits cost reports) if the information is available or is readily obtainable.  CMS 
contacts the provider or supplier directly or solicits the aid of the MAC to determine the 
providers or suppliers Medicare fiscal year ending date.  There should be no delay 
issuing this notice even if the fiscal year information is not obtainable or is not known at 
the time of certification. 
 
This procedure assures that CMS contacts a responsible official or officer of the provider 
or supplier for this information and allows several days for the provider or supplier to 
respond when it appears the information is currently available.  The information is not 
considered readily available if the provider does not know or will decide at a later date. 
 
Item III - Change of MAC  This section is not applicable to the RO. 
 
Item IV  Termination -This section is completed when a provider or supplier 
involuntarily ends its participation in the program.  When the new owner rejects 
assignment of the existing Medicare agreement following a change in ownership it is 
treated as a voluntary termination. 
 
Item V  Remarks CMS uses this section for pertinent information.  If the provider is 
part of a chain, insert the name and address of a parent or controlling organization in this 
section.  If Form CMS-2007 corrects previously furnished information, include an 
explanation of the change. 
If a SNFs participation will end, include an explanation relating to services after 
termination (see 3008.1 and 3008.2) in the remarks.   
 
EXAMPLE: An agreement with a participating SNF is involuntarily terminated for cause 
(e.g., failure to file cost reports), and the effective date of termination is established as 
October 15, 2015.  As with all providers, this termination takes effect on (0001 hours on a  24 hour clock) October 15, 2015, and not at the close of (2400 hours on a 24 hour clock) 
October 15, 2015.  Therefore, the remarks should indicate Termination for cause--
payment can continue for up to 30 calendar days of post-hospital skilled nursing care 
services furnished on or after October 15, 2015, to beneficiaries admitted to the facility 
before October 15, 2015.  Do not make payment for new admissions which occur on or 
after October 15, 2015. 
 
2783D  Distribution 
(Rev. 201, Issued: 06-19-20, Effective: 06-19-20, Implementation: 07-27-20) 
 
Whenever there is a change to Form CMS-2007 (new provider or supplier, change in 
MAC, or involuntary termination) CMS forwards a copy to the providers or suppliers 
MAC. 
 
2784 - Effective Date of Certification of Coverage for Suppliers of 
Services 
(Rev. 1, 05-21-04) 
 
The effective date of certification of coverage is the date the SA survey is completed if the 
supplier is found in compliance with applicable Conditions for Coverage and all other 
applicable Federal requirements. 
 
If the supplier is found not to be in compliance with all Conditions for Coverage, and all 
other applicable requirements on the date the survey is completed, then its effective date 
will be the earlier of the following dates: 
 
  The date on which the supplier meets all requirements; or 
 
  The date on which the supplier is found to meet all Conditions for Coverage and 
the supplier submits an acceptable PoC for lower level deficiencies or an 
approvable waiver request, or both.  (See 42 CFR 489.13.) 
 
The effective date is linked to the survey date.  The RO ensures that the SA surveys the 
supplier promptly after notification that the supplier has enrolled and is fully operational.  
The RO uses Exhibit 166 to notify a supplier of its approval.  
 
Provider agreements and supplier participation are determined in the same fashion.  
Medicaid has no suppliers; they are all providers. 
 
NOTE: RHCs and ASCs, which are suppliers, are subject to the provisions of category-
specific agreements which function like provider agreements.  When notifying RHCs or 
ASCs of initial certification, complete, countersign and enclose the appropriate Health 
Insurance Benefits Agreement Form, Form CMS-1561A (Exhibit 4B), or Form CMS-370 
(Exhibit 65), respectively.  An FQHCs attestation statement serves as its benefit 
agreement. 
 
The RO notifies Part B carriers of the effective dates of coverage for all suppliers.   
2800 - Strikes at Participating Facilities 
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) 
 
When employees of a participating hospital, SNF/NF or ICF/IID go on strike against the 
facility, the RO obtains a written report from the SA about that institutions continuing 
ability to furnish adequate care to its patients and on the steps taken to assure the health 
and safety of its patients based on the SAs onsite visit to the facility.  If a strike takes 
place in an accredited facility, a visit by the SA to determine whether the strike has caused 
a decline in the quality of care furnished, is appropriate. 
 
The report should focus on the specific situations.  For example, if the nursing staff is on 
strike, the SA should indicate what the facility is doing to minimize any hazards that 
might arise due to inadequate nursing, such as securing temporary nurses and limiting 
admissions to emergency cases.  The report should also describe the SA plans for 
monitoring the situation. 
 
Because of the sensitive nature of this area, the SA and RO should not create the 
impression that the Federal Government is taking sides in a labor dispute.  However, be 
alert to all types of situations that could lead to substandard care being provided to 
beneficiaries. 
 
    Organ Procurement Organizations 
 
2810 - Organ Procurement Organizations (OPOs)  Citations - Statutory 
Authority 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
Section 1138 (b)(1) of the Social Security Act (the Act) authorizes the Secretary to 
provide payment under Medicare or Medicaid to hospitals/CAHs and transplant centers 
for the cost of organs procured from organ procurement organizations (OPOs) only if the 
organization: 
 
  Is a qualified OPO operating under a grant made under 371(a) of the Public Health 
Service Act (PHSA), or has been certified or recertified by the Secretary within the 
previous four  years as meeting the standards to be a qualified OPO; 
 
  Meets applicable requirements of Medicare or Medicaid for OPOs; 
 
  Meets performance-related standards prescribed by the Secretary; 
 
  Is a member of and abides by the rules and requirements of the Organ Procurement 
and Transplantation Network (OPTN) designated by the Secretary pursuant to 372 of 
the PHSA.  (The United Network for Organ Sharing (UNOS) operates the OPTN 
under a contract with the PHS); 
 
  Allocates organs, within its service area and nationally, in accordance with medical 
criteria and the policies of the OPTN; and 
 
  Is designated or re-designated by the Secretary as an OPO under 1138 of the Act. 
 
To be designated as the OPO for a service area, an organization must at the time of 
application and throughout the period of designation meet these statutory requirements.  
Further, the Act requires that the Secretary may not designate more than one OPO for each 
service area, as described in 371 (b)(1)(E) of the PHSA and 1138 (b)(2) of the Act. 
 
2810.1 - Definitions 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
Certification means a CMS determination that an OPO meets the requirements for 
certification at 42 CFR 486.303. 
 
Decertification means a CMS determination that an OPO no longer meets the 
requirements for certification at 42 CFR 486.303. 
 
Designation means CMS assignment of a geographic service area to an OPO.  Once an 
OPO is certified and assigned a geographic service area, organ procurement costs of the 
OPO are eligible for Medicare and Medicaid payment under Section 1138(b)(1)(F) of the  Act. 
 
Open area means an OPO service area for which CMS has notified the public that it is 
accepting applications for designation. 
 
Organ Procurement Organization (OPO) means an organization that performs or 
coordinates the procurement, preservation, and transport of organs and maintains a system 
for locating prospective beneficiaries for available organs. 
 
Re-certification cycle means the 4-year cycle during which an OPO is certified. 
 
Transplant Hospital means a hospital that provides organ transplants and other medical 
and surgical specialty services required for the care of transplant patients.  There may be 
one or more types of organ transplant centers operating within the same transplant 
hospital. 
 
Urgent need occurs when an OPO is non-compliant with one or more conditions for 
coverage and this has caused, or is likely to cause, serious injury, harm, impairment, or 
death to a potential or actual donor or an organ recipient. 
 
2811 - OPO Requirements for Certification 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
42 CFR 486.303 details the following requirements that an OPO must meet in order to be 
certified by CMS.  A qualified OPO: 
 
1.  Must have received a grant under 42 U.S.C. 273(a) or have been certified or re-
certified by the Secretary within the previous 4 years as being a qualified OPO; 
 
2.  Be a non-profit entity that is exempt from Federal income taxation under section 
501 of the Internal Revenue Code of 1986;  
 
3.  Have accounting and other fiscal procedures necessary to assure the fiscal stability 
of the organization, including procedures to obtain payment for kidneys and non-
renal organs provided to transplant hospitals; 
 
4.  Have an agreement with CMS, as the Secretarys designated representative, to be 
reimbursed under Title XVIII for the procurement of kidneys;  
 
5.  Have been re-certified as an OPO under the Medicare program from January 1, 
2002 through December 31, 2005;  
 
6.  Have procedures to obtain payment for non-renal organs provided to transplant 
centers;  
 
7.  Agree to enter into an agreement with any hospital or CAH in the OPOs service 
area, including a transplant hospital that requests an agreement;    
8.  Meet or have met the conditions for coverage for OPOs, including both the 
outcome measures and the process performance measures; and 
 
Meet the provisions of Titles XI, XVIII, and XIX of the Act, section 371(b) of the PHSA, 
and any other applicable Federal regulations. 
 
2812 - OPO Designation Requirements 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
An OPO must be designated by CMS and must enter into an agreement with CMS in order 
for the OPO to be reimbursed under Medicare and Medicaid for the costs of organ 
procurement. 
 
42 CFR 486.306(b) and (c) details the requirements that an OPO must meet for service 
area designation, service area location, and characteristics. 
 
42 CFR 486.308 specifies that CMS designates only one OPO per service area and that 
the service area is only open for competition after the OPO designated for that area is de-
certified and all administrative appeals have been completed under 486.314, or the OPO 
voluntarily withdraws from the program.  A designated OPO may only change its service 
area boundaries as a result of a merger or consolidation with another OPO after advance 
approval by CMS as noted in 486.310 (a).  An OPO must compete for an entire service 
area according to 486.316(c)(3). 
 
An OPO is normally designated for a 4-year agreement cycle.  In the case of a voluntary 
termination of its agreement, CMS will open the service area for competition to fill the 
remaining term of the 4-year agreement cycle.  A designation period may be longer than 
the 4-year agreement cycle in instances where CMS requires a longer period of time to 
select a successor to an OPO that has been de-certified or has voluntarily terminated. 
 
2812.2 - Waivers 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
A certified hospital/CAH must enter into an agreement only with the OPO designated for 
the service area in which the hospital/CAH is located, unless CMS has granted the 
hospital/CAH a waiver under 486.308(e).  A hospital/CAH may request and CMS may 
grant a waiver allowing the hospital to have an agreement with a designated OPO outside 
of its service area.  To qualify for a waiver, the hospital must submit data to CMS as 
detailed in 42 CFR 486.308(e)(1) and (2).  In making a determination on waiver requests, 
CMS considers the requirement under 42 CFR 486.308 (f)(1)-(4): 
 
  Cost effectiveness; 
 
  Improvements in quality; 
 
  Changes in a hospitals designated  OPO due to changes in the definition of  metropolitan statistical areas, if applicable; and 
 
  The length and continuity of a hospitals relationship with an OPO other than the 
hospitals designated OPO. 
 
A hospital/CAH may continue to operate under its existing agreement with an out-of-area 
OPO while CMS is processing the waiver request.  If the waiver is denied by CMS, the 
hospital/CAH must enter into an agreement with the OPO designated for its service area 
within 30 days of notification of the final determination as noted in 486.308(g). 
 
2812.3  Opening the Donation Service Area (DSA) for Competition 
from other OPOs (42 CFR 486.316)  
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
The CMS RO opens an OPOs DSA for competition if: 
a.  CMS terminates or de-certifies the OPO (involuntary termination) during the 
current certification period due to non-compliance with the Conditions for 
Coverage; 
b.  The normal four year certification period has ended and CMS declines to renew its 
agreement with the OPO under 486.316 (non-renewal of an agreement); or 
c.  An OPO ceases to operate or CMS has reasonable grounds for anticipating it will 
cease to operate (voluntary termination by the OPO).  
 
For a voluntary termination including a cessation of business, the RO opens the DSA for 
competition on the CMS-approved effective date of the termination.  For an involuntary 
termination of an OPO or the non-renewal of an OPOs agreement, the RO will open the 
area for competition either on the date of the completion of the administrative appeals 
process which upholds the termination action or once the time to file an appeal has passed 
and the OPO has declined to do so.  A de-certified OPO cannot compete for its open area 
or any other open area. 
 
Simultaneously with opening the DSA for competition, the RO will request a transition 
plan from the non-renewed OPO that provides details on how all aspects of the OPO 
operation will be transmitted, including time frames, to a new OPO (see SOM Section 
2812.4(a)-(l) below). 
 
The CMS RO will announce the opening of the DSA in an email to all currently certified 
OPOs and the Association of Organ Procurement Organizations.  The following entities 
will be copied on the communication:   
 The CMS Center for Medicare;  
 The CMS Medicare Administrative Contractor for the non-renewed OPO (Form 
CMS-2007 Provider Tie-In Notice ) (required);and  
 The Health Resources and Services Administration (HRSA).   
 
The announcement will specify what information must be submitted by any OPO 
applicant, the deadline for submission of an application (which will be set at 45 calendar 
days from the date of the announcement), and the expected timeframe for selection of an  applicant (which will generally be 30 calendar days from the application closing date).  In 
the case of involuntary termination or non-renewal of an agreement, CMS may extend the 
agreement of the de-certified OPO to facilitate transition to a new OPO. 
 
In order to apply for an open DSA, an applicant OPO must meet the following criteria: 
a.  Be in compliance with two out the three outcome measure requirements at 42 CFR 
486.318; 
b.  Be at or above 100 percent of the mean national rate averaged over the  years of 
the re-certification cycle for the outcome measures at 42 CFR 486.318; 
c.  Be at least 15 percentage points higher than the donation rate at 42 CFR 486.318 
of the OPO currently designated for the service area; 
d.  Be in compliance with the requirements for certification at 42 CFR 486.303, 
including the conditions for coverage at 42 CFR 486.320 through 42 CFR 486.348; 
and 
e.  Compete for the entire service area. 
 
2812.4  Application 
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
The applicant must submit the following information to the CMS RO by the deadline set 
out in the open competition announcement: 
  Completed CMS -Form 576A; 
  Transition plan that includes timelines for all aspects of the transition including, 
but not limited to:  
a.  Physical location (office);  
b.  Policies for community outreach;  
c.  Coordination with transplant hospitals in the DSA;  
d.  Coordination with donor hospitals in the DSA;  
e.  Coordination with tissue and eye banks in the DSA;  
f.  Constitution of an Advisory Board;  
g.  Governing Body oversight of the successful transition of the DSA; 
h.  Plan for staff retention or additions to ensure adequate and trained staff 
coverage in the open area; 
i.  Transfer of donor data;  
j.  Name of Medical Officer; 
k.  A plan for prompt response to hospital referrals; and 
l.  Plan for identifying and addressing the unique challenges of the DSA 
which impact the performance of the OPO. 
 
2812.5 - Application Review 
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
The applicant OPO must submit its application by the specified deadline to the CMS RO 
for review.  The RO will assemble a panel to review the applications.  Each application 
will be reviewed according to the following criteria at 42 CFR 486.316(d): 
a.  Compliance with the outcome measures at 42 CFR 486.318; 
b.  Compliance with 42 CFR 486.320 through 42 CFR 486.348;  c.  Contiguity to the open service area; and  
d.  Success in identifying and overcoming barriers to donation within its own service 
area and the relevance of those barriers to barriers in the open area. An OPO 
competing for an open service area must submit information and data that describe 
the barriers in its service area, how they affected organ donation, what steps the 
OPO took to overcome them, and the results. 
 
2812.6 - Selection Process 
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
The CMS RO will complete a review of all applications within 30 calendar days of the 
application closing date. The RO will either make a selection of a successor OPO for the 
DSA or decline to accept all applications (see below at SOM Section 2812.8).  The OPO 
selected will be notified of this selection in writing by the RO and the DSA will be 
redesignated to the selected OPO.  The following entities will be copied on the 
communication to the OPO:   
  The CMS Center for Medicare; 
  The CMS Medicare Administrative Contractor (Form CMS-2007, Provider Tie-In 
Notice);  
  The Association of Organ Procurement Organizations (AOPO); and  
  The Health Resources and Services Administration (HRSA). 
 
2812.7 - OPO Transition 
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
The newly designated OPO will submit a monthly summary to the CMS RO to report on 
its transition activities.  The CMS RO will monitor the transition process to ensure 
successful oversight and management of OPO operations.  The RO will conduct a full 
survey of the newly designated OPO within six months of the transition to determine 
compliance with the Conditions for Coverage. 
 
2812.8 - No OPO applications for the open DSA 
(Rev. 179, Issued: 07-06- 18, Effective: 07-06-18, Implantation: 07- 06-18) 
 
If no OPO applies for an open DSA or if CMS declines to accept all applications, CMS 
may select a single OPO to take over the entire open DSA or may adjust the service area 
boundaries of two or more contiguous OPOs to incorporate the open DSA. The RO will 
make its decision based on the selection criteria at 42 CFR 486.316(d). 
 
2813  Re-Certification Cycle (42 CFR 486.309) 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
An OPO is considered re-certified if it meets the standards of a qualified OPO within the 
4-year period beginning from August 1, 2006 through July 31, 2010; August 1, 2010 
through July 31, 2014; August 1, 2014 through July 31, 2018; August 1, 2018 through 
July 31, 2022; and onwards.    
An OPO is surveyed once every four years and its service area is not opened for 
competition when the OPO: 
 
  Meets all 3 outcome measure requirements at 42 CFR 486.318; and 
 
  Has been shown by the results of a survey to be in compliance with the certification 
requirements at 42 CFR 486.303, including the conditions for coverage at 42 CFR 
486.320 through 486.348. 
 
2814  Change in Control/Ownership or Service Area (42 CFR 486.310) 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
The applicable CMS RO must be notified before a designated OPO implements a change 
in either ownership or control or in its service area.  The OPO must provide information to 
the CMS RO that is specific to the board structure of the new organization, as well as 
operating budgets, financial information, and other written documentation the CMS RO 
determines to be necessary for designation.  A designated OPO considering a change in its 
service area must obtain prior CMS RO approval. 
 
If an OPOs change of ownership or control is of such an extent that it no longer meets the 
requirements for designation as an OPO, as determined on Form CMS-576, CMS may 
de-certify the OPO and designate its service area an open area.  The OPO may appeal such 
a de-certification under 486.314.  The service area is not opened for competition until the 
conclusion of the administrative appeals process.  The OPO must submit a revised Form 
CMS-855 (Medicare Enrollment Application) to the FI/MAC with any change of control 
or ownership. 
 
* See 2812.3 Open Competition 
 
When the CMS RO receives notification of a prospective change in control or ownership 
for a designated OPO, the CMS RO must determine, based upon the documents submitted, 
that the operation of the OPO will continue uninterrupted and continue to satisfy Medicare 
and Medicaid requirements during and following the changeover of ownership or control.  
The CMS RO will review all the documents submitted by the OPO, including its 
responses to the elements on Form CMS-576.  If the RO approves the CHOW/change of 
control and the OPO proceeds with change of ownership a new CMS Form 576 must be 
signed by the person designated by the governing body to be responsible for operations. 
The OPO should show evidence of transition planning to ensure continuity.  Confirm with 
the Fiscal Intermediary/MAC that the OPO has submitted a revised CMS Form-855 and 
that the information has been accepted. 
 
De-certification (42 CFR 486.312) 
 
2815  De-certification and Competition: 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
  If an OPO does not meet all 3 outcome measures as outlined in 42 CFR 486.318 or if it 
has been shown by survey to be out of compliance with the requirements described in 42 
CFR 486.320 through 486. 348, the OPO is de-certified.  If the OPO does not appeal the 
de-certification, or if the OPO appeals and the reconsideration official and the CMS 
hearing officer uphold the de-certification, the OPOs service area is opened for 
competition from other OPOs.  The OPO that has been de-certified is not permitted to 
compete for its open area or any other open service area. 
 
2817 - Voluntary Termination of an Agreement: 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
The OPO must submit to the applicable CMS RO a written notice of its intention to 
terminate its agreement and include a stated proposed effective date.  CMS has the option 
to agree to the proposed effective date or set another termination date no later than six 
months from the OPO requested date, or set a different date less than six months after the 
proposed effective date if it determines a different date would not disrupt services in that 
area.  If CMS determines that the OPO has ceased providing services to its donation 
service area, then that cessation of services is considered a voluntary termination by the 
OPO, with the effective date to be determined by CMS. 
 
After approval from CMS of the date for voluntary termination, the OPO must provide 
public notice of its voluntary termination in local newspapers within three (3) business 
days from the approval date.  The notice should include the date the OPO will cease 
operations and services, a list of hospitals and CAHs in the OPOs service area, and the 
OPO telephone contact numbers for inquiries.  The OPO must provide the CMS RO with 
copies of each public notice within seven (7) business days of CMSs approval of 
voluntary termination.  No further payments under Title XVIII or XIX of the Act will be 
made with respect to costs attributable to the OPO on or after the effective date of de-
certification. 
 
* See also 2812.3 Open Competition 
 
2818 - Involuntary Termination and Non-renewal of an Agreement: 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
During the term of an OPO agreement, CMS may terminate an agreement with an OPO at 
any time the OPO no longer meets the requirements for certification at 42 CFR 486.303.  
Additionally, CMS will not voluntarily renew its agreement with an OPO if the OPO fails 
to meet the requirements for certification at 486.318, based on findings from the most 
recent re-certification cycle, or the other requirements for certification at 486.303.  If 
CMS determines that the OPO is out of compliance with one or more Conditions for 
Coverage and the OPO does not implement an approved plan of correction that re-
establishes compliance prior to the end of a designated period of time, CMS will begin the 
process of de-certification.   CMS may also immediately terminate an agreement in cases 
of urgent need as defined in 42 CFR 486.302.  CMS will decertify the OPO as of the 
effective date of the involuntary termination or as of the ending date of the agreement in 
the case of non-renewals.    
* See also 2812.3 Open Competition 
 
Except in cases of urgent need, CMS will give the OPO written notice of the intent to de-
certify at least 90 days before the effective date of de-certification.  CMS provides public 
notice of the effective date of de-certification in local newspapers in the OPOs service 
area.  The notice will state the reasons for de-certification and the effective date.  No 
further payments under Title XVIII or XIX of the Act will be made with respect to costs 
attributable to the OPO on or after the effective date of the de-certification.  In cases of 
urgent need, follow the procedures found in Appendix Q: Immediate Jeopardy. 
 
2819 - Appeals (486.314) 
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
Involuntary Termination/Non-Renewal of Agreement: 
 
An OPO may appeal an involuntary termination or non-renewal of an agreement on 
substantive and procedural grounds.  CMS sends a notice of initial de-certification 
determination to the OPO which contains the reasons for the determination, the effect of 
the determination, and the OPOs right to seek reconsideration.  The notice letter 
informing the OPO of de-certification and impending termination must include the 
appropriate appeal rights as well as instructions on how to file a request for 
reconsideration.  
 
Reconsideration of a De-certification:  
 
An OPO has 15 business days from receipt of CMS notice of de-certification to seek 
reconsideration from CMS if it is dissatisfied with the de-certification determination.  The 
OPO reconsideration request must state the issues or findings of fact with which the OPO 
disagrees, the reasons for disagreement and factual support for each finding with which 
they disagree, and the reasons for disagreement.  The OPO may submit factual support for 
each findings with which they disagree as well as additional information and arguments as 
to why it should not be decertified.  CMS then evaluates the submitted information to 
determine if the de-certification decision is upheld or reversed.  An OPO must seek 
reconsideration before it is entitled to seek a hearing before a hearing officer.  If the OPO 
does not request reconsideration from CMS, or fails to submit its request timely to CMS, 
the OPO has no right to further administrative review and the de-certification is final.   
 
CMS Reconsideration Determination:  
 
A written reconsidered determination is made by CMS within 10 business days of the 
request for reconsideration.  This determination will affirm, reverse or modify the initial 
de-certification determination and the findings on which it was based and will determine 
whether the submitted documentation and information was sufficient to support a change 
in the initial decision.  If the determination decision is reversed or modified, CMS notifies 
the OPO in writing with a revised Form CMS-2567 to reflect the revised findings. If the 
decision is not reversed or modified, but is affirmed, CMS notifies the OPO in writing of  the decision, including what materials CMS reviewed and why the submitted 
documentation did not justify a reversal or modification in the initial decision to de-
certify.  Additionally, CMS informs the OPO that it will not be eligible to compete for the 
current service area or any other service area opened for competition.  CMS will augment 
the administrative record to include any additional materials submitted by the OPO and a 
copy of the reconsideration decision, and sends the supplemented administrative record to 
the CMS hearing officer.  If the OPO timely seeks further administrative review (hearing), 
CMS forwards the initial request for reconsideration and all supporting documentation to 
the hearing officer. 
 
Administrative Hearing:  
 
An OPO that wishes to appeal the reconsideration decision of CMS must file a written 
hearing request within forty (40) business days of the receipt of the notice of CMS 
reconsideration decision.  If a hearing request is not submitted or received timely by CMS, 
than the OPO has no further right to appeal or other administrative review.  The 
Administrative Appeal Process is handled through the Office of Medicare Hearings and 
Appeals. 
 
Administrative Record: 
 
The administrative record consists of, but is not limited to, (1) factual findings from the 
survey(s) on the OPO conditions for coverage; (2) data from outcome measures; (3) 
rankings of OPOs based on the outcome data; and (4) correspondence between CMS and 
the affected OPO.  The hearing officer sends the administrative record to both parties 
within ten (10) business days of receipt of the OPOs written request for hearing. 
 
2820 - Outcome Measures/Data Reporting (486.318, 486.328): NOT 
REVIEWED ON SITE  
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
Data measures as calculated by University of Michigan Kidney Epidemiology and Cost 
Center (UM-KECC) utilizing the Scientific Registry of Transplant Recipients (SRTR) 
data and OPTN reporting data are entered into the OPO database for CMS CO/RO review 
for regulatory compliance. 
 
2821 - Information Management (486.330):  
(Rev. 111, Issued: 04-11-14, Effective: 04-11-14, Implemetation: 04-11-14) 
 
The OPO is required to keep and maintain donor and transplant recipient records in a 
human readable and reproducible paper or electronic format for a minimum of seven (7) 
years.  Federally Qualified Health Centers 
 
2825 - Federally Qualified Health Centers (FQHCs) - Citations and 
Description 
(Rev. 1, 05-21-04) 
 
2825A - Citations 
(Rev. 40, Issued: 03-20-09, Effective: 03-20-09, Implementation: 03-20-09) 
 
Section 4161(a)(2) of OBRA 90 (P.L. 101-508) amended 1861(aa) of the Act and 
established FQHC services as a benefit under the Medicare program effective October 1, 
1991.  The statutory requirements that entities must meet to be considered an FQHC for 
Medicare purposes are at 1861(aa)(4) of the Act.  Regulations establishing the FQHC 
benefit and outlining Conditions for Coverage for FQHCs were published on June 12, 
1992, in the Federal Register (57 FR 24961) and became effective on the date of 
publication.  These regulations were amended on April 3, 1996 (61 FR 14640).  Section 
13556 of OBRA 1993 (P.L. 103-66) amended 1861(aa) of the Act by adding outpatient 
health programs or facilities operated by a tribe or tribal organization under the Indian 
Self-Determination Act or by an urban Indian organization receiving funds under title V of 
the Indian Health Care Improvement Act, as entities eligible to participate in Medicare as 
FQHCs. 
 
2825B - Description 
(Rev. 85, Issued: 07-19-13, Effective: 07-19-13, Implementation: 07-19-13) 
 
The Federally Qualified Health Centers (FQHCs) are considered suppliers under Part B 
of Medicare and are paid Part B benefits for FQHC services.  For the purpose of Medicare 
enrollment, an FQHC is defined as an entity that has entered into an agreement with CMS 
to meet Medicare program requirements under 42 CFR 405.2434, and: 
 
  Is receiving a grant under Section 330 of the Public Health Service (PHS) Act; or 
 
  Is receiving funding under a contract with the recipient of a Section 330 grant, and 
meets the requirements to receive a grant under 330 of the PHS Act; or 
 
  Is an FQHC Look-Alike, i.e., the Health Resources and Services Administration 
(HRSA), has notified the facility it has been determined to meet the requirements 
for receiving a Section 330 grant, even though it is not actually receiving such a 
grant; or 
 
  Was treated by CMS as a comprehensive federally funded health center as of 
January 1, 1990; or 
 
  Is an outpatient health program or facility operated by a tribe or tribal organization 
under the Indian Self-Determination Act or by an Urban Indian organization 
receiving funds under title V of the Indian Health Care Improvement Act. 
  2826 - RO Approval Process for FQHCs 
(Rev. 40, Issued: 03-20-09, Effective: 03-20-09, Implementation: 03-20-09) 
 
2826A - General 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
An FQHC applicant seeking to enroll as a Medicare-participating supplier is subject to a 
filing procedure instead of SA certification or recertification. Under this procedure, the 
FQHC applicant must attest that it is in compliance with all applicable Medicare 
regulations.  To attest to being in compliance, the facility must be open and operational 
when the attestation is signed.  The SA does not survey to confirm the FQHC applicants 
compliance with Medicares regulations.   
 
FQHCs must remain in substantial compliance with all of the FQHC regulatory 
requirements specified in 42 CFR Part 405, Subpart X, and in 42 CFR Part 491, with the 
exception of Section 491.3.   
 
CMS will enter into an agreement with an entity that qualifies to participate as an FQHC 
when: 
 
  The applicant provides a copy of its Notice of Grant Award by HRSA that verifies 
the applicant qualifies as an FQHC; the applicant provides a copy of its FQHC 
Look-Alike Designation Memo from CMS;  or the applicant is confirmed as a 
qualifying tribal or Urban Indian organization outpatient healthcare facility;  
 
  The applicant assures CMS through a self-attestation that it satisfies the regulatory 
requirements in 42 CFR 405 Subpart X and 42 CFR Part 491, except for Section 
491.3;  
 
  The applicant submits a complete Form CMS-855A enrollment application (along 
with all supporting documentation) to its MAC, and the MAC recommends 
approval of said application; and 
 
  The entity terminates other Medicare provider agreement(s) it has, unless it assures 
CMS that it is not using the same space, staff, and resources simultaneously as a 
physicians office or other type of provider or supplier.  For example, an RHC 
cannot concurrently be approved for Medicare as both an RHC and FQHC. 
 
In accordance with 42 CFR 491.5(a)(3)(iii), if an FQHC provides services in permanent 
units in more than one location, each such unit must be separately enrolled in the 
Medicare program.  One FQHC permanent unit cannot be provider-based to another 
FQHC unit.  However, mobile units operated by the FQHC do not require separate 
enrollment, but are considered part of the permanent FQHC unit that operates them. 
 
In general, CMS Provider Enrollment Oversight Group (PEOG) is responsible for 
reviewing and approving or denying requests for Medicare participation as an FQHC.  The 
MAC notifies the FQHC applicant and HRSAs Bureau of Primary Health Care or the  Indian Health Service, as appropriate, of approvals or denials (The only exception to this 
involves situations where the MAC determines that the applicant does not comply with the 
enrollment requirements at 42 CFR 424.500-525, in which case the contractor itself will 
issue the denial per the Program Integrity Manual).  For approvals: 
  A freestanding FQHC undergoing initial enrollment, except for a tribal or 
Urban Indian FQHC, is to be assigned to the MAC that covers the State where 
the FQHC is located. 
 
  A tribal or Urban Indian FQHC undergoing initial enrollment is to be assigned 
to the Jurisdiction H MAC. 
 
NOTE: For FQHCs already enrolled in Medicare: 
 
  All freestanding FQHCs, except for tribal or Urban Indian FQHCs, will remain 
with their originally assigned MAC, i.e., will not be moved to the MAC that 
covers the State where the FQHC is located. 
 
  All tribal and Urban Indian FQHCs will continue to be assigned to the 
Jurisdiction H MAC. 
 
It is unlikely that a new FQHC would qualify for provider-based, as opposed to 
freestanding, status, since HRSAs requirements for governance of an FQHC preclude the 
FQHC from satisfying CMS requirements for clinical, financial and administrative 
integration with the main provider.  However, 42 CFR 413.65(n) permits any FQHC or 
FQHC Look-Alike facility that, since April 7, 1995, furnished only services that were 
billed as if they were furnished by a department of a provider to continue to do so, 
regardless of satisfying the criteria for provider-based status, so long as it was qualified as 
an FQHC (not including tribal/Urban Indian facilities) or FQHC Look-Alike on or before 
April 7, 2000.  A provider-based FQHC is assigned its own CMS Certification Number 
(CCN), but uses the same MAC as the main provider to which it is provider-based.   
 
The CMS Location reviews FQHC complaints and either refers them to HRSA or the 
Indian Health Care Service (IHS), as applicable, for investigation or, in the case of 
credible allegations that allege an FQHC does not meet applicable Medicare requirements, 
to the SA for investigation. The CMS Location will conduct an investigation of any 
complaint allegation that a FQHC does not meet applicable Medicare requirements when 
the FQHC is located on reservation property. Surveyors are to use the State Operations 
Manual (SOM), Chapter 5-Complaint Procedures and Appendix G Guidance for 
Surveyors: Rural Health Clinic (RHC) and Federal Qualified Health Centers (FQHCs) 
when conducting a FQHC complaint investigation. (See 2826H.)  
 
The CMS Location may terminate the agreement with an FQHC if it finds that the FQHC 
no longer meets the Medicare eligibility standards to participate as an FQHC and/or is not 
in substantial compliance with the Medicare requirements for FQHCs. 
 
2826B - Information to Be Provided to Potential Applicants 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21)   
The MACs are to provide potential applicants for enrollment as an FQHC a copy of the 
document entitled Information on Medicare Participation for FQHCs (Exhibit 179).  This 
document includes information on:  
 
  Obtaining a copy of Form CMS-855A enrollment application from CMS Web site 
at https://www.cms.gov/Medicare/CMS-Forms/CMS-
Forms/Downloads/cms855a.pdf; and 
 
  Attestation Statement for FQHCs (Exhibit 177) 
 
2826C - Request to Participate 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
To participate in the Medicare program, applicants seeking initial enrollment as an FQHC 
must submit a Form CMS-855A application: 
 
  In the case of applicants that are operated by a tribe or tribal organization, to 
the jurisdiction H A/B MAC; and  
 
  In the case of all other applicants, to the A/B MAC that covers the State where 
the applicant facility is located.  (Previously all FQHC applications and claims 
were processed by one national fiscal intermediary.  This system was phased 
out as CMS has implemented the MAC contracts.  Therefore, all new FQHC 
applications are to be assigned to the applicable MAC, as described above in 
section 2826A.   
 
Information on enrollment procedures and a list of A/B MACs may be found at: 
 
  http://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-
FQHC-Center.html?redirect=/center/fqhc.asp  
(Accessed November 17, 2020) 
 
  http://www.cms.gov/medicare-coverage-database/indexes/contacts-part-a-
medicare-administrative-contractor-index.aspx?bc=AgAAAAAAAAAA&  
(Accessed November 17, 2020) 
 
  https://www.cms.gov/medicare-coverage-database/indexes/contacts-part-b-
medicare-administrative-contractor-index.aspx?bc=AAAAAAAQAAAA&  
(Accessed November 17, 2020) 
 
  https://www.cms.gov/medicare-coverage-database/indexes/contacts-part-ab-
medicare-administrative-contractor-index.aspx?bc=AAAAAAAQAAAA&  
(Accessed November 17, 2020) 
 
The following documents must be included in the application: 
    A signed and completed application Form CMS-855A enrollment application; 
 
  Signed and dated copies of the attestation statement (Exhibit 177).  To attest to 
being in compliance, the facility must be open and operational when the 
attestation is signed.  Since FQHCs must sign an agreement stipulating that they 
will comply with 1861(aa)(4) of the Act and specific FQHC regulations, this 
statement serves as the Medicare FQHC agreement when it is also signed and 
dated by CMS PEOG.   
 
  HRSA Notice of Grant Award or FQHC Look-Alike Designation  that includes an 
address for the site of the applicant which matches the practice location reported 
on the Form 855A;  
 
  Form CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement; 
 
  Clinical Laboratory Improvement Act (CLIA) Certificate (if applicable).  Facilities 
that examine human specimens for the diagnosis, prevention, or treatment of any 
disease or impairment of, or the assessment of the health of, human beings is 
considered a laboratory and must meet CLIA requirements.  These facilities must 
apply and obtain a certificate from the CLIA program that corresponds to the 
complexity of tests performed.  Certain types of laboratories and laboratory tests 
are NOT subject to meeting CLIA requirements.  One example would be facilities 
which serve only as collection stations.  A collection station receives specimens to 
be forwarded to a laboratory performing diagnostics test.  Chapter 6, Section 6002 
of the SOM provides additional details regarding laboratories and laboratory tests 
NOT subject to CLIA requirements.  It is the responsibility of the FQHC applicant 
to review the CLIA requirements and obtain a CLIA certificate if needed.  Neither 
the MAC nor CMS can make a determination as to whether the FQHC applicant 
must obtain and submit a CLIA certificate; and 
 
  Copy of State License (if applicable). 
 
2826D - Processing Requests 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
The MAC will review the completed Form CMS-855A and other documents submitted by 
the applicant to ensure all required information and documentation has been provided, and 
thus is complete.  A complete FQHC application consists of: the Form CMS-855A, two 
signed original Attestation Statement for Qualified Health Centers (Exhibit 177), a copy of 
the HRSA Notice of Grant Award, a copy of the applicants State license if applicable, 
and a copy of its CLIA certificate, if applicable.  Upon completion of its review, the MAC 
will either:  (1) forward its recommendation for approval of the application to CMS 
PEOG; or (2) deny the enrollment application based on enrollment criteria.  
 
If the MAC recommends approval, CMS PEOG will sign the approval letter, and 
countersign and date both of the applicants Attestation Statement for Federally Qualified 
Health Centers (Exhibit 177).  CMS PEOG will use the date the FQHC application was  considered complete by the MAC (i.e., the date of the approval recommendation to CMS 
PEOG) as the effective date.  In addition, CMS PEOG will update the national database 
system and issue the FQHCs CCN, and will send the countersigned attestation to the 
MAC contractor. Following receipt of this information from CMS PEOG, the MAC will 
provide the approval letter to the FQHC and include the countersigned attestation, with a 
carbon copy of the approval letter to the applicable CMS Location.   
 
In the event the enrollment application is denied on the basis of enrollment criteria, the 
MAC will process the denial and will provide the denial letter to the FQHC applicant, 
with a carbon copy to the CMS Location. MACs are not required to forward denials to 
CMS PEOG. 
 
For outpatient health programs or facilities operated by a tribe or tribal organization or by 
an Urban Indian organization receiving funds under title V of the Indian Health Care 
Improvement Act, the MAC confirms the applicants attestation by using the IHS lists of 
facilities or organizations provided by the CMS Location, or by contacting the CMS 
Location or the IHS for applicants not on the list. 
 
Each MAC should designate a primary point-of-contact (POC) for coordination with 
HRSA, IHS, and CMS. 
 
2826E - RO Assigning Applicants an FQHC CMS Certification Number 
(CCN) 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
The PEOG assigns each FQHC permanent site that it approves, a CCN using the 1800-
1989 series.  This includes RHCs converting to FQHCs.  The CMS PEOG retires the CCN 
of the RHC and notifies the FQHC replacing the RHC of its new CCN. 
 
2826F - Effective Date 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
If the MAC determines that the FQHC application is complete and recommends approval 
to CMS PEOG, CMS PEOG then signs and dates the applicants Attestation Statement for 
Federally Qualified Health Centers (Exhibit 177).  CMS PEOG follows the CMS 
enrollment guidelines for FQHCs in establishing the effective date (see Program Integrity 
Manual) and in accordance with 42 CFR 489.13. CMS PEOG will use the date the FQHC 
application was considered complete by the MAC (i.e., the date of the approval 
recommendation to CMS PEOG) as the effective date. The MAC will send the approval 
letter and countersigned attestation to the FQHC after it receives it from CMS PEOG.     
 
2826H - Complaint Investigations 
(Rev. 203, Issued: 03-12-21, Effective: 03-12-21, Implementation: 03-12-21) 
 
CMS investigates complaints which raise substantial allegation of noncompliance by an 
FQHC with Medicare requirements and health and safety standards found at 42 CFR 405 
Subpart X, and 42 CFR 491 Subpart A, except for 42 CFR 491.3.  In conducting  complaint investigations, SAs (or CMS Location in the case of tribal FQHCs) use the 
instructions in Chapter 5, particularly 5200 through 5240, and Appendix G of the SOM 
to determine whether the FQHC is in substantial compliance with Medicare requirements. 
 
If the FQHC is found not to be in substantial compliance with Medicare requirements, 
then the CMS Location may initiate termination of the CMS agreement with the FQHC, in 
accordance with the provisions at 42 CFR 405.2436.  The CMS Location will follow the 
appropriate termination procedures and document and report as required.  (See SOM 
Chapter 3, 3010-3028 for termination procedures.)  If a determination is made to 
terminate the FQHCs provider agreement, the CMS Location will notify the FQHC in 
writing of its intention to terminate the agreement at least 15 days before the termination 
date stated in the notice.  An FQHC may appeal CMS decision to terminate its agreement 
in accordance with the provisions at 42 CFR Part 498. 
 
CMS refers complaints about FQHCs that do not involve Medicare health and safety 
standards found at 42 CFR Part 491 Subpart A, to HRSA or the IHS, as applicable. 
 
The IHS investigation referrals are coordinated with CMS Native American Contacts 
(NAC).  The HRSA investigation referrals are coordinated with HRSAs Bureau of 
Primary Care, Division of Policy and Development, Policy Branch. 
    NOTE: Under the Defense of Marriage Act (DOMA):  Every psychiatric hospital/facility 
is expected to recognize all state-sanctioned marriages and spouses for purposes of 
compliance with the Conditions of Participation and regulatory requirements, regardless of 
any laws to the contrary of the state or locality where the hospital/facility is located.  In 
the regulation or this guidance, and in every instance where the following terms appear: 
 
  spouse means an individual who is married to another individual as a result of a 
state-sanctioned marriage, including a same-sex marriage, regardless of whether the 
state where the facility is located permits such marriages to occur; 
 
  marriage means a state-sanctioned marriage, including a same-sex marriage, 
regardless of whether the state where the facility is located permits such marriages to 
occur;  
 
  family includes, but is not limited to, an individuals spouse (see above); and 
 
  relative, when used as a noun, includes but is not limited to, an individuals 
spouse (see above). 
 
Furthermore, wherever the text of a regulation or associated guidance includes a 
reference to a patients representative,  surrogate, support person, next-of-kin,  
or similar term in such a manner as would normally implicitly or explicitly include a 
spousal relationship, the terms are to be interpreted as indicated above.  2830  Psychiatric Residential Treatment Facilities (PRTF)  Citations 
and Definitions 
(Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15) 
 
2830A  Citations 
 
Sections 1905(a)(16) and (h) of the Act provide that inpatient psychiatric services for 
individuals under age 21 include only inpatient services that are provided in an institution 
(or distinct part thereof) that is a psychiatric hospital as defined in section 1861(f) of the 
Act or in another inpatient setting that the Secretary has specified in regulations.  
Additionally, the Childrens Health Act of 2000 (Pub. L. 106310) imposes procedural 
reporting and training requirements regarding the use of restraints and involuntary 
seclusion in facilities, specifically including facilities that provide inpatient psychiatric 
services for children under the age of 21 as defined by sections 1905(a)(16) and (h) of the 
Act.  (42 CFR 483.350(a)). 
 
Condition of Participation (CoP).  The Condition of Participation for PRTFs is contained 
in 42 CFR Part 483, Subpart G: Condition of Participation for the Use of Restraint or 
Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric 
Services for Individuals Under 21.  Appendix N of this manual contains the Interpretive 
Guidelines for surveyors. 
 
2830B  Definitions 
 
A Psychiatric Residential Treatment Facility (PRTF) is defined as a facility other than 
a hospital, that provides psychiatric services, as described in subpart D of part 441 of this 
chapter, to individuals under age 21, in an inpatient setting.  Sections 441.151, in subpart 
D of 42 CFR indicates that PRTFs must be accredited by the Joint Commission, the 
Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on 
Accreditation of Services for Families and Children (COA), or by any other accrediting 
organization with comparable standards that is recognized by the State.  PRTFs, as 
indicated in 483.374 must also have either a current provider agreement with the State 
Medicaid agency or if enrolling as a Medicaid provider must execute a provider agreement 
with the State Medicaid agency. 
 
Inpatient Psychiatric Services for Individuals Under age 21 Benefit.  Inpatient 
psychiatric services for individuals under 21 is a Medicaid benefit as provided by section 
1905(a)(16) of the Social Security Act, the provision of these services is an optional 
benefit for individual states.  Although a state may choose to or not to offer PRTF services 
in its state plan, the benefit must be provided in all States to those individuals who are 
determined during the course of an Early and Periodic Screening, Diagnosis, and 
Treatment (EPSDT) screen to need this type of inpatient psychiatric care.  Under the 
EPSDT provisions at section 1905(r)(5) of the Act, States must provide any service listed 
in section 1905(a) of the Act that is needed to correct or ameliorate defects and physical 
and mental conditions discovered by EPSDT screening services, whether or not the 
service is covered under the State plan. 
Condition of Participation for the Use of Restraint and Seclusion.  PRTFs must  comply with the requirements of 42 CFR 483.350, subpart G in order to participate in the 
Medicaid program.  The interpretive guidelines for the Condition of Participation may be 
found in Appendix N and include discussion of the following eleven standards of the 
Condition: 
  General requirements for psychiatric residential treatment; 
  Resident protections; 
  Orders for the use of restraint or seclusion; 
  Consultation with treatment team physician; 
  Monitoring of residents in and/or immediately following restraint or seclusion; 
  Requirements for notifying parents or legal guardians; 
  Application of time out; 
  Post-intervention debriefing; 
  Medical treatment for injuries resulting from an emergency safety intervention; 
  Facility reporting requirements; 
  Facilitys responsibility in educating and training its staff. 
 
Emergency safety situation means unanticipated resident behavior that places the 
resident or others at serious threat of violence or injury if no intervention occurs and that 
calls for an emergency safety intervention as defined in this section. 
 
Emergency safety intervention means the use of restraint or seclusion as an immediate 
response to an emergency safety situation. 
 
Minor means a minor as defined under State law and, for the purpose of this as defined in 
483.352, includes a resident who has been declared legally incompetent by the applicable 
State court. 
 
Resident means an individual under age 21(as described in subpart D of 441.151) 
receiving psychiatric treatment in a PRTF. 
 
Restraint means a personal restraint, mechanical restraintordrug used as a restraint, 
as defined in this section. 
 
Seclusion means the involuntary confinement of a resident alone in a room or an area 
from which the resident is physically prevented from leaving. 
 
Serious injury means, any significant impairment of physical condition of resident as 
determined by qualified medical personnel.  This includes but is not limited to, burns, 
lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether 
self-inflicted or inflicted by someone else. 
 
Staff means individuals who participate in caring for the resident, who have the 
responsibility for managing a resident's treatment and who are employed by the facility on 
a full-time, part-time, or contract basis. 
 
Time out means the restriction of a resident for a period of time to a designated area from 
which the resident is not physically prevented from leaving, for the purpose of providing  the resident an opportunity to regain self-control. 
 
Drug used as a restraint means any medication that is administered to manage a 
resident's behavior, which may have temporary effect of restricting the resident's freedom 
of movement; and is not a standard or routine treatment for the resident's medical or 
psychiatric condition. 
 
2831  Determination-Making Authority 
(Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15) 
 
2831A  Survey Agency and State Medicaid Agency Interaction 
 
Section 1902(a)(33) of the Act requires that the same State survey agency (SA) that 
certifies Medicare provider and supplier eligibility also make the determination of 
eligibility to participate in Medicaid.  The law also requires that there be a separately 
designated single SA responsible for the overall management of the Medicaid program (42 
CFR 431.610(b)).  Therefore, in each State, a State Medicaid Agency (SMA) is ultimately 
responsible for Medicaid program administration.  Each SMA enters into an interagency 
agreement with its certifying SA establishing the determination-making function of the SA 
and providing for the application of Federal certification standards and procedures. 
 
In addition, 42 CFR 431.610(e) and (f) require that the Medicaid State plan must designate 
the agency that is responsible to ensure that institutions and agencies meet the 
requirements for participation in the Medicaid program.  The SMA must accept the SAs 
certification decisions as final, but exercise its own determination whether to enter into an 
agreement with psychiatric residential treatment facilities (PRTFs), while if the SA 
determines the PRTF is out of compliance, the SMA may not enter into an agreement.  
The SMA is responsible for reviewing certifications to ensure that the SA adhered to 
procedural requirements.  If the SMA disagrees with the SAs certification, the SMA 
should first contact the SA to resolve the issue.  If the issue is not resolved after contact 
with the SA, the SMA should present the issue to the applicable CMS-Regional Office 
(RO). (See discussion in State Medicaid Manual (SMM) 2084.3A). 
 
2831B  Authorization of Certification Expenditures 
 
Authority to approve Medicare certification budgets and expenditures is delegated to the 
designated CMS Consortium or Regional Administrator(s).  Authority to approve or 
disapprove Federal Financial Participation (FFP) in Medicaid certification expenses is 
delegated to the CMS Associate Regional Administrators or the Consortium Survey and 
Certification Officer where an Associate Regional Administrator is not present. 
 
2831C  Look-Behind Authority on State Determinations 
 
The Secretary has authority under 1902(a)(33), 1919(g)(3), and 1910(b)(1) of the Act 
cancel approval of all Medicaid facilities that do not meet Federal health or safety 
requirements.  Such a determination is in lieu of, or overrides a determination by the State 
and is binding on the SMA. Section 1902(a)(33) of the Act gives CMS the authority to  question State determinations regarding Medicaid facilities' compliance with Federal 
requirements and authorizes CMS to make independent and binding determinations 
concerning the extent to which individual institutions and agencies meet requirements for 
participation.  CMS has the authority to look behind State determinations and, with 
cause, to make binding determinations.  This authority allows CMS to validate State 
determinations concerning the extent to which individual institutions and agencies meet 
the requirements for participation (Section 1902 (a)(33)(B) of the Act). 
 
This look behind authority accords CMS the ability to cancel the approval of a facility to 
participate in the Medicaid program when CMS determines the facility fails to comply 
substantially with the Conditions of Participation. (See Section 1902 (a)(33)(B) and SMM 
2084.3).  Also refer to 42 CFR Part 483, Subpart G for PRTF Conditions of Participation. 
 
Another part of CMSs look- behind authority provides that a provider agreement is 
considered by CMS to be invalid for purposes of providing FFP to the State if the State 
failed to adhere to federal procedures.  For example, the SMA may have issued the 
provider agreement even though the SA determined that the facility was not in compliance 
with the COP.  In that case, the agreement is void from its inception.  This authority is 
established by Section 1902 (a)(33)(B) of the Act. (See discussion of look behind 
authority in SMM 2084.3 and SOM 3042). 
 
2831D  Appeals 
 
2831D.1- State Appeals 
 
A State has the right to appeal the Administrators decision to withhold federal funds for 
Medicaid programs due to failure to comply with the Federal regulations; as stated in 42 
CFR Part 430 Subpart D (a) This subpart sets forth the rules for hearings to States that 
appeal a decision to disapprove State plan material (under 430.18) or to withhold Federal 
funds (under 430.35), because the State plan or State practice in the Medicaid program is 
not in compliance with Federal requirements. (b) Nothing in this subpart is intended to 
preclude or limit negotiations between CMS and the State, whether before, during, or after 
the hearing to resolve the issues that are, or otherwise would be, considered at the hearing.  
Such negotiations and resolution of issues are not part of the hearing, and are not governed 
by the rules in this subpart except as expressly provided. 
 
2831D.2  Facility Appeals 
 
If a Medicaid-only facility requests a hearing, such hearing must be completed either 
before or within 120 days after the effective date of the adverse action.  (See SMM 
2040.)  Detailed Medicaid appeal procedures are provided by the State.  In the case of 
look-behind terminations, CMS notifies the facility of the termination and whether it has 
a right to request a hearing before a Federal Administrative Law Judge.  Although a 
facility can appeal a look-behind determination that found the facility out of compliance 
with the conditions of participation, the facility has no right to request for an appeal in 
cases where CMS disallowed FFP on the grounds of an SAs improper or inappropriate 
certification of the facility. (See SMM 2084.3E).   
2831E  Accreditation 
 
Federal regulations at 42 CFR 441.151(2)(ii) require that PRTFs are  to be accredited by 
the Joint Commission, the COA, the CARF or by any other accrediting organization with 
comparable standards that is recognized by the State. 
 
2832  Survey Agency, State Medicaid Agency, and PRTF 
Responsibilities & Obligations 
(Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15) 
 
2832A  Attestations 
 
State Responsibilities  The SA of the State which is surveying the PRTF inputs the initial 
attestation information into ASPEN, and continually thereafter. 
  PRTF Responsibilities  PRTFs must submit attestation statements to each SMA 
where they have established a provider agreement. 
  Attestation statements are to be submitted annually and are due on July 21st of each 
fiscal year.  However, if July 21st occurs on a weekend or holiday, the attestation is 
due on the first business day following the weekend or holiday. 
  Attestations must include the following information: 
  Facility General Characteristics: name, address, telephone number of the facility, 
and a State provider identification number; 
  Facility Specific Characteristics:  
+  Bed size; 
+  Number of individuals currently served within the PRTF who are provided 
service based on their eligibility for the Medicaid Inpatient Psychiatric 
Services for Individuals Under age 21 Benefit (Psych under 21); 
+  Number of individuals, if any, whose Medicaid Inpatient Psychiatric Services 
Under 21 Benefit is paid for by any State other than the State of the PRTF 
identified in this attestation letter; and 
+  List all States from which the PRTF has ever received Medicaid payment for 
the provision of Psych under 21 services. 
  The signature of the facility director; 
  The date the attestation was signed; 
  A statement certifying that the facility currently meets all of the requirements of 
Part 483, Subpart G governing the use of restraint and seclusion; 
  A statement acknowledging the right of the SA (or its agents) and, if necessary, 
CMS to conduct an on site survey at any time to validate the facilitys compliance 
with the requirements of the rule, to investigate complaints lodged against the 
facility, or to investigate serious occurrences; 
  A statement that the facility will submit a new attestation of compliance annually 
and in the event a new facility director is appointed. 
 
2832B  Plan of Correction (POC) 
  Regulations at  42 CFR 488.28(a) allow recertification of providers with deficiencies at the 
Standard or Condition level only if the facility has submitted an acceptable Plan of 
Correction (POC) for achieving compliance within a reasonable period of time acceptable to 
the Secretary. Failure to submit a POC may result in termination of the provider agreement as 
authorized by 489.53(a)(1).  After a POC is submitted, the certifying SMA, or in some cases 
the CMS Regional Office, makes the determination of the appropriateness of the POC for it to 
be acceptable. 
 
2832C  Assigning CMS Certification Numbers (CCN) 
 
A CCN code is assigned based on where the PRTF is physically located.  Processing of 
requests for payment is usually keyed to the Federal identification number; however this 
identification number is for Online Survey, Certification, and Reporting System (OSCAR) 
tracking purposes only. 
 
The certification numbers for PRTFs will have five digits and one letter.  The first two 
digits identify the State in which the PRTF facility is located.  This number is then 
followed by the letter L and is then followed by three digits and is numbered according to 
the order in which a facility was identified as a PRTF in their State.  All State codes are 
listed in SOM 2779.  For example, a PRTF located in Maryland would have a State code 
of 21.  This would then be followed by the letter L and identified with a three digit 
number.  For example, if it was the fourth PRTF identified by the State, the PRTFs CCN 
would be 21L004. (See SOM 2779B) 
 
2832D  ASPEN Data Input 
 
  The surveying SA has the responsibility of entering the survey data into ASPEN.  
After the CCN is assigned to the PRTF, the SA is to enter information received from 
the PRTF annual attestation as well as information from recertification or complaint 
surveys.  It is also the responsibility of the SA to update the information as needed.  
The SA is to input information from Forms CMS- 1539, CMS- 670, CMS-2567 and if 
applicable, CMS-2567B. 
 
  The initial input of information from attestation must be done by the SA of the State 
surveying the PRTF, even if the State in which the PRTF is located does not include 
the Inpatient Psychiatric Services for Individuals Under 21 Benefit in its State plan. 
 
  Maintaining attestation and survey information is the responsibility of the SA 
conducting complaint and validation surveys. 
 
2832E  Multi-State Issues & Interagency Relationships 
 
2832E.1  State-to-State Differences 
 
There are several State-to-State differences in the provision of services for individuals 
who qualify for the Inpatient Psychiatric Services for Individuals Under 21 Benefit.  The 
following factors determine where an individual receives services and who has surveying  responsibilities. 
 
1.  States may or may not have the Inpatient Psychiatric Services for Individuals Under 21 
benefit in their State plan. 
2.  States may or may not have a PRTF within its borders. 
3.  States have an obligation to provide inpatient psychiatric services for individuals under 
21 years of age regardless of whether or not the benefit is in their State plan or a PRTF 
is within its borders. 
 
A State will either have the Inpatient Psychiatric Services for Individuals Under 21 
Benefit in its State Plan or it will not.  However, not all States will have a PRTF within its 
borders that can meet the needs of its Medicaid beneficiaries and thus will have to transfer 
beneficiaries to another State to receive the needed service. 
 
Occasionally, a SMA may elect to send a patient out of State to receive the Psych Under 
21 Benefit, (reference S&C Memo of July 3, 2013: 13-45-PRTF).  It is the responsibility 
of the transferring SMA to ensure that these services are provided in a certified PRTF.  In 
some instances, the facility selected (i.e., receiving facility) is located in a State that does 
not include PRTF services in its Medicaid State Plan and thus no facilities in that State are 
certified as PRTFs.  If the transferring SMA still wishes to transfer the patient to such a 
facility, it must make a written agreement for the certification of that facility prior to the 
patients transfer. 
 
The initial certification of a PRTF is currently accomplished through an attestation 
process.  The SA, through an agreement with the SMA, conducts surveys (Recertification, 
Complaint Investigation, and Validation) at least every five (5) years to ensure that the 
facility remains in compliance with the applicable regulations and the assertions of the 
attestation.  The SA makes a recommendation to the SMA for re-certification or 
termination.  The SMA enters into a written agreement with the PRTF. 
 
If the certifying SMA of one State wishes to have a facility in another State certified as a 
PRTF, there are three options available for the SMA regarding the survey portion of the 
certification process: 
  The SMA may make a written agreement with the SA of the State in which the 
facility is located to conduct the surveys of the facility;  
  The SMA may make a written agreement with the SA located within their own 
State to travel to the receiving State to conduct the surveys; or 
  The SMA may make a written agreement with any other SA to conduct the surveys 
of the facility. 
 
SAs in States where the Medicaid State Plan does not include PRTF services may not have 
trained personnel or may not have the available resources to conduct these PRTF surveys 
since this is not a routine part of their workload.  If the SMA of one State wishes to certify 
a PRTF in another State and approaches the other States SA to conduct the survey 
activity, the other SA may agree if they feel they have the necessary resources or may 
decline if they feel they do not.  They are under no obligation to perform the work for the 
SMA of another State.   
If the SA from the State where the facility is located is not able to perform the survey 
activity, the SMA seeking survey of the PRTF may enter into a written agreement with 
any other State SA (including the SA located within in SMAs own State) that has the 
resources and appropriately trained personnel.  The SA that conducts the surveys would 
then be responsible for inputting the survey information into ASPEN.  The SMA 
requesting the survey will ensure that the survey information is entered into ASPEN and 
ensure that re-certification surveys are conducted at least once every five (5) years.  The 
SMA requesting the survey has the authority to enforce non-compliance actions. 
 
2832E.2  Action for Non-Compliance and Termination 
 
The SMA may take termination action against the PRTF if the SA determines the PRTF is 
not in compliance with the regulation or fails to appropriately report a death incident.  If 
there are conflicting determinations between the SA and the SMA or there are conflicts 
that arise based on multi-state issues, then the applicable RO must be informed of the 
decisions.  The RO will settle these conflicts before adverse findings are placed into 
ASPEN.  In the case of multi-state issues, if the SA and the SMA are located in two 
different Regions, the applicable RO is defined as the RO for the state in which the SMA 
is located.  The facility must submit their plan of correction to the SA of the State that 
conducted the survey. 
 
If the survey findings do not rise to the condition level, but are only standard level 
deficiencies, it is still the responsibility of the surveying State to send their findings to the 
certifying SMA and the applicable Regional Office (RO).  It is the responsibility of the 
certifying SMA to review and accept the facilitys plan of correction. 
 
2832E.3  State Agency  Who Can Survey 
 
The SMA identifies which agency is responsible for conducting survey and certification 
oversight for its PRTFs.  Federal regulation requires that the Medicaid State plan must 
designate, as the State authority responsible for establishing and maintaining health 
standards for private or public institutions that provide services to  Medicaid beneficiaries, 
the same State agency that is used by the Secretary to determine qualifications of 
institutions and suppliers of services to participate in Medicare. (Emphasis added).  (See 
42 CFR 431.610(b)). 
 
During surveys to determine compliance with the PRTF condition of participation, if 
findings show that the condition of participation for the PRTF is not met it is the 
responsibility of the SMA of the State that certified the PRTF to consider termination of 
the provider agreement.  If findings do not rise to the condition level, but are standard 
level deficiencies, it is still the responsibility of the surveying State to send their findings 
to the SMA and the applicable RO.  Facilities where standard level deficiencies have been 
found are required to submit a plan of correction to the surveying SA. 
 
2833  Survey Process 
(Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)   
2833A  Survey Types 
 
2833A.1  Recertification Surveys 
 
SAs are required to validate the attestation statements for a 20 percent of all PRTFs in 
their state on an annual basis.  Validation requires that the SA review attestation letters, 
conduct on-site review of PRTFs based on criteria established in 42 CFR 441.151 through 
441.156, and determine compliance with federal standards and regulations, as set forth in 
42 CFR 483, Subpart G and further discussed in the interpretive guidelines. 
 
2833A.2  Complaint Surveys 
 
1.  Immediate Jeopardy  
The SA conducts an investigation of all allegations which may represent an immediate 
jeopardy situation within 2 working days of complaint receipt.  
 
Immediate Jeopardy, as defined in 42 CFR 489.3, is a situation in which the providers 
noncompliance with one or more requirements of participation has caused, or is likely to 
cause, serious injury, harm, impairment, or death to a resident. Serious injury is defined 
as any significant impairment of the physical condition of the resident as determined by 
qualified medical personnel.  The term serious injury can be equated with abuse or 
neglect.  Appendix Q lists abuse and neglect as a trigger to call an immediate jeopardy.  
Refer to appendix Q for complete guidance on immediate jeopardy.  To determine if an 
immediate jeopardy situation is present and ongoing, an assessment of each complaint 
intake must be made. 
 
Exception  If the SA receives a restraint/seclusion death report, the SA should complete 
the investigation of this report within 5 working days of receipt of survey authorization 
from the RO.  This investigation involves both on-site and off-site review.  The ACTS 
report should be reviewed to determine facility history. 
 
2.  Non-immediate jeopardy  
For non-immediate jeopardy situations, the SMA in conjunction with the SA will establish 
a mechanism by which to prioritize the nature of complaints.  The SA should assess 
facility compliance with the established standards and regulations as provided in 42 CFR 
part 483 subpart G, (483.350 through 483.376) with additional guidance at 441.150 
through 441.156.  If a complaint is received by CMS, CMS will notify the appropriate SA, 
who will then notify the SMA about the complaint, any ongoing investigation, findings, or 
decision regarding the complaint. 
 
The SMA must report all serious occurrences, as defined in 42 CFR 483.374(b), to its SA 
and the SA must conduct both recertification and complaint surveys based on regulations 
established by the 42 CFR 483 subpart G and further discussed within the interpretive 
guidelines as established in Appendix N.  The SA will be advised annually in the CMS 
Mission and Priority Document (MPD) on the expected validation requirements for its 
States psychiatric residential treatment facilities.   
2833B  Survey Frequency 
 
1.  Frequency  The SAs are required to conduct recertification surveys for 20 percent 
of all PRTFs in the state each year and for all PRTFs within a State within a 5-year 
period.  Complaint surveys do not count towards a States 20 percent required 
recertification surveys. 
 
2833C  Survey Procedures 
 
Pre-survey procedures, onsite survey procedures, required CMS forms, and the 
interpretive guidelines are located in Appendix N. 
 
2833C 1 PRE-SURVEY PROCEDURES 
 
Under CMS policy, surveys for all providers and suppliers must be unannounced.  While 
the unannounced surveys may sometimes result in some minor difficulties, this policy and 
practice represents public attitudes and expectations toward effective compliance with the 
regulation and survey standards.  If there is any conflict with internal State policies and 
practices, the State survey agency (SA) should discuss the problem with its State Medicaid 
Agency (SMA). 
 
2833C.2 ON-SITE SURVEY PROCEDURES 
 
2833C.2a ENTRANCE CONFERENCE 
 
The entrance conference sets the tone for the entire survey.  The surveyor should be well 
prepared, courteous, and make requests, not demands.  Upon arrival, the surveyor does the 
following:  
  Presents the appropriate identification; 
  Introduces other team members who must also furnish appropriate identification; 
  Informs the facilitys administrator, director, or supervisor of the purpose of the 
Survey;  
  Provides expected duration and time schedule of the survey; and 
  Provides the facility with an overview of the survey and explains the process. 
 
During the entrance conference, the surveyors should: 
A.  Request a listing of all residents at the facility, including their age or date of birth, 
and who in the past 12 months: 
  Have been secluded or restrained; 
  Have been placed in time out; 
  Received medication for behavior management; 
  Have been injured or hospitalized as a result of restraint or seclusion intervention; 
  Had a serious occurrence that was reported regardless of whether it is related to a 
safety intervention.  A Serious occurrence as defined in the regulations is a 
residents death, serious injury to a resident, or a residents suicide attempt;    Was transferred to a hospital for acute care services; and 
  Died while in the facility.  
 
B.  Inform the facility  that the survey process will include: 
  A physical onsite tour of the facility; 
  Direct observations, and interviews with residents, families/guardians, and 
personnel involved in the residents care, (ask that appropriate family and 
guardians be made aware of potential interviews); and 
  Review of relevant program, treatments, and residents records. 
 
C.  Establish personnel availability and discuss approximate time frames for survey 
completion. 
 
D.  Provide approximate or expected exit date and time. 
 
E.  Ask if there are any locked areas which require a key for entry, and if there are 
locked areas, how would the surveyor be able to access those areas. 
  
F.  Ask the facility to identify which staff will be available for questions/assistance.  
 
G.  Provide a list and category of the facility staff the surveyor will need to interview 
during the course of the survey. 
 
2833C.3. Survey Team Composition  
 
Survey team size and composition will vary according to the size of the facility and the 
purpose of the survey.  Professional disciplines and experience represented on the survey 
team should reflect the expertise needed to determine compliance with the CoP.  All 
survey team members must meet education and training qualifications as specified in the 
SOM 4009 and must have successfully completed the CMS Basic PRTF survey training 
course. 
 
Any SA or federal surveyor who serves on the PRTF survey team must have completed 
the PRTF basic survey training course successfully. 
 
2833C.4- INFORMATION GATHERING  
 
2833C.4a TASK 1 - REPRESENTATIVE SAMPLE OF RESIDENTS - SELECTION 
METHODOLOGY 
 
Purpose of the Sample - The purpose of drawing a sample of residents from the facility is 
to ensure all the regulatory requirements is applied to a proportionate representation of all 
residents.  The sampling methodology outlined below is not intended to create a 
"statistically valid" sample.  The methodology allows for flexibility in sample selection 
based on the surveyors observations while on-site at the facility. 
 
The surveyor must conduct interviews and observations of the sampled residents within  the context of the environment in which the resident lives, receives treatment and spends 
leisure time.  Although focus should be on the sampled residents, the behavior and 
interactions of all other residents and staff within the environment also contributes to the 
total context. 
 
After the resident sample is collected, additional information about the facility's practices, 
as well as additional resident information may emerge.  Surveyors may add residents to 
the sample based on observations or incidents that occur during the survey.  The reason 
for adding residents to the sample must be documented.  Surveyors must add any resident 
who is restrained or secluded during the survey to the sample.  A resident substitution may 
be made in the sample only if it is determined that including such a resident in the sample 
would negatively impact his/her treatment.  For example, when interviewing/observing a 
resident with diagnosis of paranoid schizophrenia, may result in acute exacerbation of 
psychiatric symptoms.  When a substitution is made within the sample, surveyors must 
ensure that the resident added to the sample meets the same requirements, and is selected 
from the same age group as the resident he/she is replacing. 
 
Sample Considerations  
  Survey team should not allow the facility to select the resident sample. 
  Sample selection should be completed before beginning review of residents or 
other survey activities. 
  Survey team must randomly select sample from the list of all the residents 
provided by the facility. 
  The sample should represent various age groups of the facility residents. The 
three main age groups are: ages 18 to 21; 9 to 17 and under 9 years. 
  The sample should include residents who experienced restraint, seclusion or 
time-out in the past 12 month (if any); these residents should make up at least 
50% of total sample. 
 
Sample Selection: 
Follow the guidance below using the appropriate ratio to select and calculate the size of 
the sample. 
 
Census :                         Sample Ratio: 
 
4-8 residents                          4 residents 
9-16 residents                        6 residents 
17-50 residents                      8 residents 
51 or more residents                     10 residents 
 
 
 
NOTE:   
  Due to unique characteristics the PRTF population and the seriousness of the 
Condition of Participation, surveyors should investigate further when a facility 
reports they have no current residents who have experienced either an ESI or time 
out procedure.   
To maximize the advantage of an interdisciplinary survey team, the survey team leader 
assigns each member an equitable number of individuals on whom to focus.  Each 
member of the team shares salient data about findings relative to his or her assigned 
individuals.  Consult with one another, on a regular basis during the survey, to maximize 
sharing of data, knowledge and competencies. 
 
Documentation  Document the sample on form CMS-807 Surveyor Notes Worksheet -
The team leader must ensure that information related to the sample is well documented 
and includes the following: 
 
1.  Summary listing of all resident information comprising the survey sample 
(including any additions or substitutions to the sample).  At a minimum, identify: 
 The record number of each resident chosen to be part of the sample; 
 Any resident-identifier codes used as a reference to protect the resident's 
confidentiality; and 
 The record number of each death record reviewed. 
 
2.  Description of the representative sample selection must include: 
 The number of residents in the sample; 
 The distribution of the individuals in the sample; 
 The number, if any, of the residents added to the sample, including the reason 
added,e.g., complaint investigation; and  
 The number, if any, of the residents substituted in the sample, including the 
reason for withdrawing the original resident record. 
 
2833C.4b TASK 2 - RECORD REVIEW OF INDIVIDUALS IN THE SAMPLE 
 
Review each resident's record to determine appropriate compliance with the condition of 
participation (CoP) for the use of restraint or seclusion, and the regulation requirements in 
42 CFR  441.151 through 441.182.  The primary purpose of the record review is to 
determine if the facility is complying with the requirements of: 
1)  Certification of need for services; 
2)  Individual plan of care (treatment plan); 
3)  Documentation of emergency situation and all events surrounding it;  
4)  Management and outcome of emergency safety intervention; and 
5)  Health and wellness of the residents.  
 
During record review, surveyors should be alert to instances of intramuscular medication 
use, safety hold and escort procedures, and any other procedures that could be mislabeled 
as not being restraints or seclusion.  Utilize direct observations, resident interviews and 
record review to make informed compliance decisions.  Ensure that the facilitys 
definitions and perception of seclusion and restraint is in consonance with the definition 
that is contained in the regulation. 
 
While reviewing the records, pay attention to key requirements such as:  compliance with 
treatment team members credentials, facility/program accreditation, and trends that may  suggest that seclusion and restraint intervention are being overused or misused.  Also look 
for records of accidents and incidents which may suggest residents abuse, neglect, 
bullying or vulnerability to injury.  If there is any evidence of physical, verbal, emotional, 
or sexual abuse; surveyors must follow-up on the status and if required, implement the 
immediate jeopardy procedure as directed by Chapter 5 and Appendix Q of the SOM. 
 
2833C.4c TASK 3- REVIEW OF OTHER RECORDS 
 
A. Death Records - Review a list of all resident deaths, in the past 12 months.  All team 
members must participate in the record review of residents who have died while at the 
facility.  For death records, refer to form CMS-726, CMS Death Record Review Data 
Sheet.  Evidence should exist of documented contact with appropriate Federal, State and 
local agencies notifying of the circumstances and demographics surrounding the residents 
death and resulting outcomes from investigation by the PRTF and/or any of the 
appropriate Federal, State or local agencies. 
 
B. Complaint Investigations - If a complaint is being investigated at the time of the survey, 
include the record(s) of the resident(s) of the complaint as part of the record review.  If the 
resident named in the complaint is still in the facility, add him/her to the sample. 
 
C. Policy and Procedures  Review the facilitys policy and procedure documents on 
restraint, seclusion, and time out interventions.  The policy must contain information about 
management of emergency safety intervention (ESI), and the facilitys procedures 
regarding all the requirements of the CoP. 
 
D. Serious Injury and Occurrence Report Review all PRTFs serious injury and 
occurrence reports for at least past twelve months prior to the date of the present survey.  
Some individual state laws may preclude the facility from sharing detailed records of the 
incident. In such case, provide PRTFs an option as to whether or not they share these 
actual reports.  In these States, surveyors should request a written summary of these 
reports.  The PRTFs should provide this summary, as well as a copy of or citation to the 
applicable state law, within one working day of the entrance conference. 
 
2833C.4d TASK 4 - DIRECT RESIDENT OBSERVATIONS 
 
The purpose of direct observation is to determine the existence of effective therapeutic 
relationship between the facility staff and the residents.  Staff must respect the rights of 
the residents and interact with them in a mutually productive manner.  Direct observation 
also helps to determine how effective staff manages the milieu and efficiency of the 
application of de-escalation and other behavior management techniques.  De-escalation 
techniques include: limit setting, therapeutic communication, redirection, conflict 
resolution, active listening techniques, and visualization. 
 
Observe each sampled resident in as many treatment settings (therapy groups, activities, 
treatment team meetings, other types of meetings, and milieu interactions in the resident's 
environment) as possible.  Visit as many treatment areas as time permits, and observe 
residents activities during different time periods, including day and evening hours, if  possible; for team members convenience or preference.  Surveyors must never request the 
facility to alter a resident's schedule so that the surveyor will not have to work at other 
than their regular work times in order to observe the resident during the survey.  The 
observation should be conducted for an amount of time sufficient to assess the sampled 
resident's responses and behaviors as well as staff responses to resident behaviors. 
  
Documentation - If during resident observation the process of documentation will disrupt 
the activity in progress, the best option is to document after the observation is completed.  
Form CMS-3070I is an optional form but can be used to record observations if the 
surveyor so chooses.  After observations are completed, compare observation result with 
the program/individual treatment plan for consistency. 
 
Record the following information for each observation: 
 Date and location; 
 Beginning and ending times of observation; 
 Number of residents present; 
 Approximate number of staff present 
 What the resident is doing (regardless of whether or not a scheduled 
therapeutic modality was in progress); 
 What the staff is doing; 
 The presence of disruptive behavior, and staff's intervention, if any; and, 
 Any other pertinent information. 
 
2833C.4e TASK 5 INTERVIEWS 
 
Resident Interviews  
 
Surveyors must interview all sample residents individually.  However, an interview may 
not be conducted with a resident when it is determined by one of the individual plan of 
care team members, as described in 441.156(c), as being inappropriate for the residents 
condition.  Staff information and medical record documentation should support the 
rationale for not interviewing the resident.  
 
When interviewing residents of a PRTF a surveyor should take into consideration the 
residents age and psychiatric condition.  Interviews with residents consist of questions 
directed at determining the resident's understanding of the treatment services indicated in 
their individual care plan and progress towards goals, type and quality of relationship with 
program staff, and their restraint or seclusion episode.  In addition, the resident should be 
asked to what degree they felt safe while restrained or secluded and if they feel as if staff 
are working with them to prevent future restraint or seclusion usage. 
 
Also ascertain if the resident felt that the restraint or seclusion was warranted based on 
their behavior.  Interviewing should not take place in the direct presence of staff.  
However, a resident should be given an opportunity to have a staff member be within 
visual proximity if the resident so chooses.  When an interview is deemed inappropriate by 
the facility staff, the survey activities for review of that resident will consist of 
observations, staff interviews, and record reviews.  Resident confidentiality must be  respected, but if the surveyor does find a life-threatening situation, that information is 
shared with the staff.  Listed below are suggested processes and questions that a surveyor 
may use during an interview.  
 
Interview Setting: 
Surveyors must respect residents rights and ensure the setting of the interview is 
conducive and less restrictive.  The surveyor should: 
1.  Request permission of the resident to talk with him/her individually. 
2.  Provide the resident with information, such as surveyor name and purpose of the 
survey. 
3.  Ensure resident privacy by conducting the interview in an appropriate location 
(low stimulus, on or off unit depending on resident restrictions, staff visible for 
surveyor and resident protection, if necessary).  Staff should be easily available 
and may be present in the room, but should not be able to overhear conversation 
unless the resident makes a request for staff close physical presence. 
 
Suggested Interview Questions: 
  Can you tell me why you are in this facility? 
  Tell me about your treatment goals? 
  Do you think you are making progress towards your treatment? Can you tell me 
the names of your medications and why you are taking them?  
  Do you have the opportunity to talk to members of your treatment team on a 
regular basis and how responsive are they to your interaction? 
  Can you describe to me your experience with the last time you were restrained/ 
secluded/ in timeout? 
  Where was staff located during your restraint/seclusion/ time out? 
  Has the treatment team discussed the incident with you?  Did you and the team 
agree on a plan to reduce the frequency of these incidents?  Please describe the 
plan to me. 
  Describe to me what incident that led to the restraint/seclusion/time out? 
 
Age Appropriate Adjustments  Surveyors should keep in mind varying age range of 
residents in the PRTF (toddlers to adolescents or young adults) and adjust their interview 
approach accordingly for a better result.  For example, there are times when kneeling or 
sitting in a chair may be less intimidating to residents, and more appropriate to begin a 
conversation.  Also the way a question is framed may determine how much information 
one can elicit, for instance, instead of asking: Can you tell me why you are in this 
facility?  The question can be reworded into different series of probing questions to get at 
a better answer.  For example, Do you like living here?  Do you know why you are 
living here?  Can you tell me about living here?  It is important to note that different 
facilities and residents may perceive or interpret restraint/seclusion intervention based on 
their own understanding and frame of reference. 
 
Staff Interviews 
 
Because milieu interaction and therapeutic intervention involve both the staff and the 
residents, it is also important to interview the staff in order to ascertain their level of  knowledge and understanding of the facilitys restraint and seclusion policies and 
procedures.  In order to ensure improved safety, staff must be adequately educated and 
oriented to their work environment.  Staff should also be familiar with resident treatment 
plans and understand their role in facilitating the residents attainment of the target 
treatment goals.  Assess for consistent treatment approaches and collaboration among the 
interdisciplinary treatment team, as well as the outcomes experienced by the residents. 
Interview the following: 
 
 Treatment team member who has assigned treatment responsibility for each 
sample resident (case manager, primary therapist, resident care coordinator, 
advocate); and 
 
 Other staff members who are involved with the resident, either through 
multidisciplinary treatment assignment (social worker, dance therapist, 
dietician) or through work assignment (professional and paraprofessional staff 
members assigned to resident's unit). 
 
During staff interviews, asking the following questions may help to elicit improved 
cooperation and more information: 
 Do you participate in the interdisciplinary treatment team; if yes, what role do 
you play? 
 Did you contribute to treatment plan objectives/goals for sample residents and 
updates? 
 How often is each residents treatment plan reviewed? 
 Can you describe the discharge plans for sample residents? 
 Give examples of de-escalation techniques you were taught and how you 
utilize them when dealing with residents? 
 How do you integrate treatment plan goals and objectives that have been 
developed as a result of seclusion or restraint episodes?  
 How do you manage residents emergency safety situation, and how you 
determine when to utilize a restraint or seclusion intervention?  
 Describe to me, how staff implement, manage, and discontinue time out, 
restraint or seclusion.   
 What behavior typically warrants interventions such as restraint or seclusion? 
 Do you feel you are adequately prepared (through education and training) to 
handle behavioral safety situations and emergencies related to residents care? 
 
Interviews with Parents and Legal Guardians 
 
Surveyors will make a request to facility/program staff after the entrance conference to 
give sample residents family/guardian notice of a potential for interview.  The interviews 
with parents and legal guardians should be conducted in addition to interviews with 
sampled residents.  Interviews with parents and legal guardians should be conducted at 
their convenience with an opportunity for face-to-face interviews when feasible.  In cases 
where parents or legal guardians reside in another state or are unable or unwilling to meet 
face-to-face, telephone interviews should be conducted.  Suggested questions: 
 Were you involved in formulation of your family members treatment plan and  discharge plans? 
 Are you aware of the psychiatric medications your family member is taking 
and/or being prescribed while in treatment? 
 Have you been able to communicate with members of your family members 
treatment team?  
 Do you know your family members treatment diagnosis, and do you 
understand what it means? 
 Were you informed of the facilitys policy on restraint and seclusion? 
 Was the information presented in a manner that you could understand? 
 Did you receive the information regarding the State Protection and Advocacy 
organization?  What type of information should be reported to them? 
 Were you contacted after a restraint or seclusion intervention? 
 Were you given an opportunity to participate in the debriefing following 
restraint/seclusion use? 
 
Interviews with Department Heads and/or Facility Administrator 
 
Conduct these interviews near the end of the survey if it is determined that questions were 
unanswerable by facility staff and interviewing directors or other facility leaders would 
prove useful to the survey process and the gathering of information.  Base the interview on 
information that was gathered during observations and direct interviews with residents and 
staff. 
 
Documentation  Use form CMS-807 to record each observation and interview conducted 
with residents/ parents/ legal guardians and staff.  Clearly delineate the documentation as 
an interview.  Include the date and time of each interview and the following information in 
every recorded entry: 
 
Resident: 
 The record number, any resident-identifier codes used as a reference to protect 
the resident's confidentiality, and the residents age; 
 Dates of restraint, seclusion or time out; and, 
 Summary of information obtained. 
 
Parent/ Legal Guardian: 
 Relationship to the resident; 
 Method of interview (face-to-face or telephone contact); and,   
 Summary of information obtained. 
 
Staff/ Management/ Directors: 
 Position, title and assignment of staff member; 
 Relationship to the resident or reason for interview; and, 
 Summary of information obtained. 
 
2833C.4f TASK 6 - VISIT TO EACH AREA OF THE FACILITY SERVING 
RESIDENTS   
Visit all areas in the facility where residents are permitted to spend their time, both 
structured and unstructured, as these are places where unanticipated behavior may occur 
that would require emergency interventions.  Also examine the area that is used for 
restraint as well as those devices that the facility uses as a restraint.  Other examples of 
areas to visit are:  restrooms, bathrooms, activity areas, visitation areas, therapy rooms, 
seclusion/time-out room, dining areas, bedrooms, and classrooms.  During the visit or 
tour, converse with residents and staff.  Ask open-ended questions in order to confirm 
observations, obtain additional information, or corroborate information regarding 
perceived problems.  Observe staff interactions with both residents and other staff 
members for insight into matters such as individual rights and staff responsibilities. 
 
Protocol - After residents in the sample have been assigned to team members, review the 
facility's map or building layout.  Be sure that at least one team member visits each 
residential and treatment unit prior to completing the survey.  The visit or tour can be 
conducted at any time during the course of the survey. Always obtain permission from the 
resident before entering his/her room. 
 
2833C.4g TASK 7  COMPLIANCE DETERMINATION AND PREPARATION FOR 
EXIT CONFERENCE 
 
Preparation for Exit Conference.In preparation for an exit conference, the surveyors 
should hold a pre-exit survey team conference at the conclusion of the survey and prior to 
the facility exit conference.  The survey team leader must ascertain that all survey team 
members have completed their respective survey tasks before the pre-exit meeting.  At this 
meeting, the surveyors will share their respective findings, and make team decisions 
regarding compliance with each standard, requirement, and Condition of Participation. 
Deficiencies found in more than one aspect of the CoP may be cumulative and interrelated 
and result in general or across-the-board inadequacies in resident care that may constitute 
actual or potential hazards to residents.  The team leader should record the survey team 
decisions on the CMS-807 as a record of the teams non-compliance determinations.  This 
would be the basis for a finding of noncompliance. All necessary forms must be 
completed, which may include: 
 
CMS-807 - Surveyor Notes Worksheet 
CMS-2567 - Statement of deficiencies and Plan of Correction (Post Survey) 
And if applicable 
CMS-726 - CMS Death Record Review Data Sheet 
Optional 
CMS-3070I - Individual Observation Worksheet 
 
General - It is recommended to complete the CMS-2567 as a post survey document. 
Include in the CMS-2567 all examples of evidence obtained from observations, 
interviews, and record reviews that contribute to a determination that the facility is 
deficient in a certain area. 
 
Special Circumstances - If at any time during the survey one or more team members  identify a possible immediate jeopardy, the team should meet immediately to confer.  See 
Appendix Q for the definition of and for guidance regarding determination of immediate 
jeopardy. 
 
Exit Conference.  Following the survey team meeting to determine compliance, the 
survey team should conduct an exit conference with the PRTFs administrator, designee, 
and other invited staff.  The purpose of the exit conference is to communicate preliminary 
survey team findings. 
 
Although it is CMS general policy to conduct an exit conference, be aware of situations 
that may justify discontinuation of an exit conference.  For example, if the PRTF is 
represented by a lawyer (all participants in the exit conference should identify 
themselves), surveyors may refuse to conduct or continue with the exit conference if the 
facility lawyer tries to turn it into an evidentiary hearing, or the staff creates an 
environment that is hostile, overly intimidating, or inconsistent with the informal and 
preliminary nature of an exit conference.  Refer to 2724 of the SOM. 
 
2834  Other Applicable SOM Sections 
(Rev. 132; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15) 
 
The following procedures already established in various Chapters within this manual serve 
as a basis for direction for the SA. 
 
 SOM 3010: Termination Procedures  Immediate and Serious Threat to 
Patient Health and Safety (23 Calendar Days). 
 SOM 3012: Termination Procedures  Noncompliance with one or more 
CoPs or Conditions for Coverage and Cited Deficiencies Limit Capacity of 
Provider/Supplier to Furnish Adequate Level or Quality of Care (90 Calendar 
Days). 
 SOM 3060: Appeals of Adverse Actions for Medicaid Non-State operated 
NFs (Non-State Operated) and ICF/IIDs (Not Applicable to Federal 
Termination of Medicaid Facilities) 
 SOM 5200 Investigation of Complaints Against Other than Accredited 
Providers and Suppliers. Although on its face this section applies to non-
accredited providers and suppliers, we believe this section is better suited for 
PRTFS. 
 Appendix Q  Guidelines for Determining Immediate Jeopardy  these 
guidelines apply to all certified Medicare/Medicaid entities...and to all types of 
surveys and investigations... 
 SOM 4009 Federal Surveyors Qualification Standards 
  Transmittals Issued for this Chapter 
  Rev #  Issue Date  Subject  Impl Date  CR# 
R205SOMA 03/11/2022  Revisions to State Operations Manual  03/11/2022 N/A 
(SOM), Chapter 2, Section 2779A1  
CCN for Medicare Providers 
R203SOMA 03/12/2021  Revisions to the State Operations Manual  03/12/2021 N/A 
(SOM), Chapter 2 for Federally Qualified 
Health Centers (FQHCs) 
R201SOMA 06/19/2020   State Operations Manual (SOM) Chapter 2,  07/27/2020 N/A 
The Certification Process 
R198SOMA 01/17/2020  Revisions to the State Operations Manual  01/17/2020 N/A 
(SOM) Chapter 2 and Chapter 3 
R197SOMA 01/10/2020  Revisions to the State Operating Manual  01/10/2020 N/A 
(SOM) Chapter 2; Community Mental 
Health Center (CMHC) 
R193SOMA 09/20/2019  Revisions to Medicare State Operations  09/20/2019 N/A 
Manual (SOM) Chapter 2 
R190SOMA 06/14/2019  Updates to the State Operations Manual  06/14/2019 N/A 
(SOM) Chapters 2, 3 and 9 to add 
instructions for Organ Transplant Programs. 
R188SOMA 04/26/2019  Revisions to the State Operations Manual  04/26/2019 N/A 
(SOM 100-07) Chapter 2, The Certification 
Process, Chapter 3, Additional Program 
Activities, and Chapter 4, Program 
Administration and Fiscal Management 
R184SOMA 10/17/2018  Revisions to State Operations Manual,  10/17/2018 N/A 
Chapter 2, Certification Process 
R181SOMA 09/21/2018  Revisions to State Operations Manual,  09/21/2018 N/A 
Chapter 2, Certification Process- Rescinded 
and replaced by Transmittal 184 
R179SOMA 07/06/2018  Revisions to the State Operations Manual  07/06/2018 N/A 
(SOM) Chapter Two for Organ Procurement 
Organizations (OPOs) 
R164SOM  11/04/2016  Revisions to the State Operations Manual  11/04/2016 N/A 
(SOM) Chapter 2 
R154SOM  06/10/2016  Revisions to the State Operations Manual  06/10/2016 N/A 
(SOM) Chapter 2 
R152SOM  03/25/2016  Revisions to the State Operations Manual  04/04/2016 N/A 
(SOM) Chapter 2  R150SOM  10/30/2015  Revisions to State Operations Manual  10/30/2015 N/A 
(SOM), Chapter 2, Clarification of 
Requirements for Off-Premises Activities 
and Approval of Extension Locations for 
Providers of Outpatient Physical Therapy 
and Speech-Language Pathology Services 
R146SOM  09/04/2015  State Operations Manual (SOM), Section  09/04/2015 N/A 
2185- Home Health Agencies (HHAs), 
Change of Address to a Medical 
Administrative Contractor (MAC) within 90 
Days 
R143SOM  07/31/2015  Revisions to State Operations Manual (SOM) 07/31/2015 N/A 
Chapter 2, The Certification Process and 
Appendix W, Survey Protocol, Regulations 
and Interpretive Guidelines for Critical 
Access Hospitals (CAHs) and Swing-Beds in 
CAHs 
R139SOM  04/24/2015  Revisions to the Medicare State Operations  04/24/2015 N/A 
Manual (SOM), Chapter 2, Rural Health 
Clinic Certification 
R132SOM  01/16/2015  New Additions to State Operating Manual  01/16/2015 N/A 
(SOM), Psychiatric Residential Treatment 
Facilities (PRTF) Chapter 2 
125SOM  10/31/2014  Revisions to State Operations Manual (SOM) 10/31/2014 N/A 
Chapter 2 
123SOM  10/03/2014  Revisions to State Operations Manual (SOM) 10/03/2014 N/A 
Chapters 1, 2 and 3 
R111SOM  04/11/2014  State Operations Manual (SOM) Chapter 2  04/11/2014 N/A 
Policy Revisions For Organ Procurement 
Organizations (OPOs) 
R91SOM  09/27/2013  State Operations Manual (SOM) Chapter 2  09/27/2013 N/A 
Policy and Nomenclature Revisions for 
Intermediate Care Facilities for Individuals 
with Intellectual Disabilities (ICF/IID) 
R90SOM  08/30/2013  State Operations Manual, Chapter 2, Section  08/30/2013 N/A 
2256A,CAH Distance Criteria 
R85SOM  07/19/2013  Federally Qualified Health Center (FQHC)  07/19/2013 N/A 
Medicare Participation 
R83SOM  03/15/2013  Revisions to Appendix E and Chapter 2  03/15/2013 N/A 
sections 2290-2308 of the State Operations 
Manual (SOM)  R82SOM  08/01/2012  CMS Certification Numbers for Medicaid- 08/01/2012 N/A 
Only Hospitals and new State Code for 
Foreign Countries 
R73SOM  12/02/2011  Revisions to Chapter 2, The Certification  12/02/2011 N/A 
Process, Sections 2082-2089-Hospices 
R69SOM  12/15/2010  Revisions to Chapter 2, The Certification  10/01/2010 N/A 
Process, Sections 2080-2089-Hospices, 
and Appendix M, Guidance to Surveyors, 
Hospices 
R65SOM  10/01/2010  Revisions to Chapter 2, The Certification  10/01/2010 N/A 
Process, Sections 2080-2089-Hospices, 
and Appendix M, Guidance to Surveyors, 
Hospices - Rescinded and replaced by 
Transmittal 69 
R62SOM  07/30/2010  New State Code for Missouri; New CCN for  01/03/2011 6989 
Medicaid -Only Hospitals 
R57SOM  01/29/2010  Revised Chapter 2, The Certification  01/29/2010 N/A 
Process, Section 2256H 
R53SOM  10/16/2009  Revising Chapter 2, The Certification  10/16/2009 N/A 
Process-Ascertaining Compliance With the 
Office for Civil Rights (OCR) Requirements 
R49SOM  06/12/2009  New Critical Access Hospital (CAH)  06/12/2009 N/A 
Requirements Under 42 CFR 485.610(e) 
Related to CAH Co-location and CAH 
Provider-based Locations 
R43SOM  05/01/2009  Revised Chapter 2, The Certification  05/01/2009 N/A 
Process, Section 2008A 
R40SOM  03/20/2009  Revisions to Chapter 2, The Certification  03/20/2009 N/A 
Process, Sections Relating to Federally 
Qualified Health Centers, and Exhibits 177 
and 179 
R33SOM  03/21/2008  Update to Chapter 2, The Certification  03/21/2008 N/A 
Process Sections 2021 and 2022 
R32SOM  01/18/2008  Revisions to Chapter 2, Critical Access  09/2007  N/A 
Hospitals (CAHs) and Appendix W, Survey 
Protocol, Regulations and Interpretive 
Guidelines for Critical Access Hospitals 
(CAHs) and Swing-Beds in CAHs 
R29SOM  10/12/2007  New Number Series and State Codes for  10/01/2007 5490 
CMS Certification Numbers (formerly 
OSCAR Provider Numbers) 
R28SOM  09/07/2007  Revisions to Appendix D, Guidance to  09/07/2007 N/A 
Surveyors for Portable X-ray Services  R25SOMA  04/20/2007  New Number Series and State Codes for  10/01/2007 5490 
CMS Certification Numbers (formerly 
OSCAR Provider Numbers)  Replaced by 
Transmittal 29 
R17SOMA  01/20/2006  Revisions to Chapter 2 The Certification  01/20/2006 N/A 
Process 
R16SOMA  01/10/2006  Revisions to Chapter 2, "The Certification  11/21/2005 N/A 
Process," Appendix E--"Providers of 
Outpatient Physical Therapy or Outpatient 
Speech Language Pathology (OPT/OSP) 
Services," and Appendix K-- 
"Comprehensive Outpatient Rehabilitation 
Facilities" 
R13SOM  10/21/2005  Revisions to Chapter 2, "The Certification  10/21/2005 N/A 
Process," Appendix E-- "Providers of 
Outpatient Physical Therapy or Outpatient 
Speech Language Pathology (OPT/OSP) 
Services," and Appendix K-- 
"Comprehensive Outpatient Rehabilitation 
Facilities"  Replaced by Transmittal 16 
R11SOM  08/12/2005  Revised Chapter 2--"The Certification  08/12/2005 N/A 
Process," Sections 2180E thru 2200F, and 
Appendix B--"Interpretive Guidelines: Home 
Health Agencies" 
R06SOM  04/29/2005  Expansion of State Codes for OSCAR  10/03/2005 3844 
Provider Numbers 
R03SOM  10/29/2004  Medicare Systems Acceptance of New  04/04/2005 3537 
Provider Numbers for Federally Qualified 
Health Centers (FQHC) 
R02SOM  08/20/2004  Assignment of Provider Identification  N/A  3245 
Numbers 
R01SOM  05/21/2004  Initial Issuance of Pub 100-07  N/A  N/A