Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs (Page 3 of 6) in pdf

ADVERSE ACTION EXTRACT FOR SNFs AND NFs

General

The CMS 462L is an integral tool in the implementation of the CMS regulation 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 facilities under Medicare and

nursing facilities under Medicaid, and to the process for certifying that these facilities meet the

Federal requirements for participation in the Medicare and Medicaid programs. It also specifies

the types of remedies which may be imposed on facilities that do not comply with the Federal

program participation requirements, instead of or in addition to termination of a facility’s

participation.

The form is designed to track critical adverse action — related information for skilled nursing

facilities and nursing facilities. Such information includes survey type and date, the basis for

CMS’s or the State’s decision to impose remedies; remedy type and duration, appeals and

hearing information, as well as other data associated with the imposition of remedies against

these facilities. The form is initiated when noncompliance with requirements in a facility is

identified and remedies are proposed. It is not completed for a facility in substantial compliance.

Instructions for completing the form

Part 1

Item 1

Enter the facility’s 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 3

Using codes 01 – 07, indicate the type of survey during which the noncompliance was

identified that triggered the proposed and/or imposed remedy or remedies.

Item 4

Record the name and address of the facility.

Item 5

Enter the date that the State survey agency or CMS sent the CMS-2567 (the Statement

of Deficiencies and Plan of Correction) to the facility.

Item 6

Enter the date on which this form was initiated. This date should be equal to or greater than

the date in item 5, above.

Item 7

Answer “Y” if applicable for each of these three questions. These fields may be left blank

if none of the choices describes the nature of the noncompliance.

Item 8

Enter the “Date Certain” (the date upon which the State Survey agency expects correction

of the facility’s deficiencies and on which it will certify noncompliance to CMS if those

deficiencies are not corrected).

Item 9

If applicable, enter the date on which the facility removes immediate jeopardy.

Item 10 Enter the date of the first revisit, if applicable.

Item 11 Insert the date on which the entire facility is back in substantial compliance, as defined at

part 42 CFR §488.301 Substantial Compliance.

INSTR. to FORM CMS-462L (7/95)

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Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs Page 3

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