ADVERSE ACTION EXTRACT FOR SNFs AND NFs PAR T 1 1. PROVIDER NUMBER 2. DATE OF SURVEY 3. TYPE OF SURVEY 01 Standard Health 05 Partial Extended Survey 02 Validation (FMS) Survey 06 Revisit (M
M D D Y Y ) 03 Abbreviated Survey 07 Life Safety Code 04 Extended Survey 4.
NAME AND ADDRESS 5. DATE CMS-2567 SENT TO FACILITY ...... ___________________________________________________ (M M D D Y Y) ___________________________________________________ 6. FORM ORIGINATION DATE ...................... ___________________________________________________ (M M D D Y Y) ___________________________________________________ 7.
NATURE OF NONCOMPLIANCE (IF YES ENTER Y) Immediate jeopardy? Repeated substandard quality of care for 3 consecutive standard health s urveys? Past noncompliance with civil money penalties imposed? 8. DATE CERTAIN.......................................... 15. TERMINATION DATE................................ (M M D D Y Y) 9. DATE IMMEDIATE JEOPARDY REMOVED 16. ALLEGATION OF COMPLIANCE RECEIVED (IF YES ENTER Y).................................................................. 10. REVISIT DATE 1 ........................................ 17. ENTITY TAKING FINAL ACTION 11. DATE ENTIRE FACILITY IS BACK IN........ (1=CMS, 2-MEDICAID STATE AGENCY) .................................. SUBSTANTIAL COMPLIANCE 18. HEARING REQUESTED 12. REVISIT DATE 2 ........................................ (IF YES ENTER Y AND COMPLETE PART 2) ....................... 13. DATE FINAL NOTICE SENT TO FACILITY 19. LOSS OF APPROVAL FOR NURSE AIDE TRAINING 14.
INFORMAL DISPUTE RESOLUTION DATE PROGRAM (IF YES ENTER Y, IF N/A ENTER A)..................................... (M M D D Y Y ) TYPE OF REMEDY 01 STATE MONITORING 07 CIVIL MONEY PENALTY 02 DIRECTED PLAN OF CORRECTION 08 CMS APPROVED ALTERNATIVE STATE REMEDY 03 TEMPORARY MANAGEMENT 09 TRANSFER OF RESIDENTS/CLOSURE OF THE FACILITY 04 DENIAL OF PAYMENT FOR NEW ADMISSIONS 10 TRANSFER OF RESIDENTS 05 DENIAL OF PAYMENT FOR ALL RESIDENTS 11 PROPOSED TERMINATION 06 DIRECTED INSERVICE TRAINING 20. REMEDY 21. PROPOSED EFF DATE 22. PROPOSED AMOUNT 23. REVISION 24. EFF DATE 25. END DATE PER DAY CODE (M/R) (M M D D Y Y ) (M M D D Y Y) (M M D D Y Y ) CIVIL MONEY PENALTIES 26. ADJUSTED AMOUNTS PER DAY ................. $ $ $ DATE TOTAL AMOUNT DUE DATE TOTAL AMOUNT PAID TOTAL AMOUNT DUE $ (M M D D Y Y ) (M M D D Y Y) FORM CMS-462L (7/95) PAGE 1 of 2 >>>> 2 ADVERSE ACTION EXTRACT FOR SNFs AND NFs PAR T 2 (M M D D Y Y ) 27. DATE REQUEST FOR ADMINISTRATIVE APPEAL RECEIVED BY CMS: ............................. 28. ADMINISTRATIVE LAW JUDGE (ALJ) DECISION: DATE RENDERED: ................................ 29. *CMS DETERMINATION: ........................................ 30. DEPARTMENTAL APPEALS BOARD (DAB) DECISION: DATE RENDERED: ...................... 31. *CMS DETERMINATION: ........................................ 32. DATE APPEAL FILED IN THE U. S. DISTRICT COURT: ......................................................... 33. U. S. DISTRICT COURT DECISION: DATE RENDERED: ....................................................... 34. *CMS DETERMINATION: ........................................ 35. DATE APPEAL FILED IN THE U. S. CIRCUIT COURT OF APPEALS: .................................... 36. U. S. CIRCUIT COURT OF APPEALS DECISION: DATE RENDERED: ................................. 37. *CMS DETERMINATION: ........................................ 38. DATE REQUEST FOR ADMINISTRATIVE APPEAL RECEIVED BY STATE: .......................... 39. ADMINISTRATIVE DECISION: DATE RENDERED: ................................................................ 40. *STATE DETERMINATION:..................................... 41. DATE APPEAL FILED IN THE STATE DISTRICT COURT:...................................................... 42. STATE DISTRICT COURT DECISION: DATE RENDERED: ................................................... 43. *STATE DETERMINATION:..................................... 44. DATE APPEAL FILED IN THE STATE COURT OF APPEALS: ................................................ 45. STATE COURT OF APPEALS DECISION: DATE RENDERED: ............................................. 46. *STATE DETERMINATION:..................................... DATE(S) APPEAL FILED ON BEHALF OF THE FACILITY IN STATE SUPERIOR COURT (S): (M M D D Y Y ) 47. COURT: ________________________________________________________________ 48. ________________________________________________________________ STATE SUPERIOR COURT(S) DECISION(S) RENDERED: 49.
COURT: ________________________________________________________________ 50. ________________________________________________________________ 51. *STATE DETERMINATION:..................................... * (CMS / STATE DETERMINATION CODES ARE (R = REVERSED, S = SUSTAINED, M = MODIFIED)) FORM CMS-462L (7/95) PAGE 2 of 2 >>>> 3 ADVERSE ACTION EXTRACT FOR SNFs AND NFs A. General The CMS 462L is an integral tool in the implementation of the CMS regula tion HSQ-156-F, Medicare and Medicaid Programs; Survey, Certification and Enforcement of Skilled Nursing Facilities and Nursing Facilities. The regulation sets forth Federal requirements which make significant changes to the process of surveying skilled nursing faciliti es under Medicare and nursing facilities under Medicaid, and to the process for certifying tha t these facilities meet the Federal requirements for participation in the Medicare and Medicaid prog rams. It also specifies the types of remedies which may be imposed on facilities that do not com ply with the Federal program participation requirements, instead of or in addition to termina tion of a facilitys participation. The form is designed to track critical adverse action related infor mation for skilled nursing facilities and nursing facilities. Such information includes survey type and date, the basis for CMSs or the States decision to impose remedies; remedy type and duration, appeals and hearing information, as well as other data associated with the impositio n of remedies against these facilities. The form is initiated when noncompliance with requirem ents in a facility is identified and remedies are proposed. It is not completed for a facility in substantial compliance. B. Instructions for completing the form Part 1 Item 1 Enter the facilitys 6-digit Provider Number. Item 2 Enter the date of survey. Refer to section 7304.C of the SOM to determine this date. For an abbreviated survey, use the last day onsite. Item