CMS Issues Two S&C Letters

The Centers for Medicare and Medicaid Services (CMS) has issued two Survey and Certification (S&C) letters covering survey-related issues.

S&C 17-37 provides information on the imposition of Civil Money Penalties (CMP) and includes the CMP Analytic Tool. The revised CMP Analytic Tool instructs Regional Offices on how to use Per Day and Per Instance CMPs depending on the timing of the noncompliance in relation to the survey, whether residents were harmed or abused, whether the facility has a good compliance history, and whether the noncompliance was an isolated event or persistent deficient practices were identified.

S&C 17-34 provides new guidance for the completion of Plans of Correction (PoCs). According to the State Operations Manual (SOM), an acceptable Plan of Correction must include the following:

• The plan of correcting the specific deficiency. The plan should address the processes that led 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; and
• The title of the person responsible for implementing the acceptable plan of correction.

In addition, under 42 CFR §483.10(g) Examination of Survey Results, Long-Term Care (LTC) facilities are required to post the most recent CMS Form 2567 and any PoC in effect. LTC facilities choosing to attach their PoC to the first page of the CMS Form 2567 are required to post the PoC with the publicly available CMS Form 2567.

Contact: Elliott Frost, efrost@leadingageny.org, 518-867-8832