CMS Update- S&C-14-18-NH- Updates to Changes in Chapter 7, SOM

Please be aware and educated on changes to the State Operations Manual Chapter 7. 


The S&C includes a “Reminder Regarding Survey Process Timeframes” and emphasizes the importance of certain requirements when an immediate jeopardy is identified. (pp.2-3)


Updates to State Operations Manual

§7212.3 – Mandatory Elements of Informal Dispute Resolution (pp. 36 – 39)

            Provides specific instructions related to what must be noted on the CMS Form 2567 when facility is successful during the informal dispute resolution process.

            Specifies the time frame within which a deficiency pending IDR must be entered in the Automated Survey Processing Environment system (ASPEN).


§7213 – Independent Informal Dispute Resolution (Independent IDR) (pp. 39 – 52)

            Incorporates into the State Operations Manual (SOM) Independent IDR process that was issued as Interim Advance Guidance in S&C: 12-08-NH dated December 2, 2011. 

Modifications are made to the original interim advance guidance to incorporate a later change/update  that allows all civil monetary penalties (CMPs) to be subject to escrow (see S&C: 13-57-NH). 

Clarifies when an Independent IDR is considered to be “complete.”

Requires the final Independent IDR decision to the facility must contain the result for each deficiency challenged and a brief summary of the rationale for that result.

Provides additional elements for Federal Independent IDR process.


§7516.4 – Reduction of a Civil Money Penalty by 50 Percent for Self-Reporting and Prompt Correction of Noncompliance (p. 125)

            Incorporates language into the SOM related to the Affordable Care Act provision permitting a reduction of a CMP by up to 50 percent when the facility has self-reported noncompliance to CMS.


§7529.1 – When a Civil Money Penalty Subject to Being Collected and Placed in an Escrow Account in Imposed (p. 132)

            Outlines the process to be used when the Regional Office imposes a CMP that is subject to collection and escrow.


§7534 - §7535 – Disposition of Collected Civil Money Penalty (pp. 135 – 140)

            Incorporates into the SOM the process for states’ use of Federally imposed CMPs, which was outlined in  S&C – 12-13-NH.

            Incorporates into the SOM the process of collection and use of CMPs when held in escrow.


Exhibits Updated

            Exhibit 139: Model Letter to Provider (Send with CMS-2567) (IJ Does Not Exist)

            Exhibit 141: Model Letter Notifying Provider of Results of Revisit

            Exhibit 142: Model Letter to Provider (Imposition of Remedies) (IJ Does Not Exist)

            Exhibit 143: Model Letter to Provider (Imposition of Remedies)(IJ Exists)

            Exhibit 144: Notice of Imposition of a CMP (Insert to Formal Notice)

            Exhibit 147: Notice of Payment Amount Due and Payable

            Exhibit 147A: Notice of Payment Amount Due for Placement in Escrow (IIDR Complete or Not Timely Requested – Facility is Filing Formal Appeal)

            Exhibit 354 – Model Letter to Involved Resident, Resident Representative and/or State Ombudsman – Opportunity to Provide Written Comment (IIDR Has Been Requested)