Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs
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6ADVERSE ACTION EXTRACT FOR SNFs AND NF
s
PART 1
1. PROVIDER NUMBER
2. DATE OF SURVEY
3. TYPE OF SURVEY
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01 Standard Health
05 Partial Extended Survey
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02 Validation (FMS) Survey
06 Revisit
03 Abbreviated Survey
07 Life Safety Code
(M M D D Y Y )
04 Extended Survey
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4. NAME AND ADDRESS
5. DATE CMS-2567 SENT TO FACILITY ......
___________________________________________________
(M M D D
Y Y )
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6. FORM ORIGINATION DATE ......................
(M M D D
Y Y )
___________________________________________________
___________________________________________________
7. NATURE OF NONCOMPLIANCE (IF YES ENTER 'Y')
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Immediate jeopardy?
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Repeated substandard quality of care for 3 consecutive standard health surveys?
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Past noncompliance with civil money penalties imposed?
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15. TERMINATION DATE ................................
8. DATE CERTAIN ..........................................
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(M M D D
Y Y )
16. ALLEGATION OF COMPLIANCE RECEIVED
9. DATE IMMEDIATE JEOPARDY REMOVED
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(IF YES ENTER 'Y') ..................................................................
10. REVISIT DATE 1 ........................................
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17. ENTITY TAKING FINAL ACTION
11. DATE ENTIRE FACILITY IS BACK IN ........
(1=CMS, 2-MEDICAID STATE AGENCY) ..................................
SUBSTANTIAL COMPLIANCE
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18. HEARING REQUESTED
12. REVISIT DATE 2 ........................................
(IF YES ENTER 'Y' AND COMPLETE PART 2) .......................
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13. DATE FINAL NOTICE SENT TO FACILITY
19. LOSS OF APPROVAL FOR NURSE AIDE TRAINING
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PROGRAM
14. INFORMAL DISPUTE RESOLUTION DATE
(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 )
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CIVIL MONEY PENALTIES
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26. ADJUSTED AMOUNTS PER DAY ................. $
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$
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$
DATE TOTAL AMOUNT DUE
DATE TOTAL AMOUNT PAID
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TOTAL AMOUNT DUE $
(M M D D Y Y) (M M D D
Y Y )
FORM CMS-462L (7/95)
PAGE 1 of 2
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