Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs (Page 4 of 6) in pdf

Item 12

Enter the date of the second revisit, if applicable.

Item 13 Enter the date that CMS or the Medicaid State Agency sent the final notice of imposition

of remedies (the letter informing the facility of the remedy or remedies to be imposed, the

effective date or dates, and the facility’s appeal rights).

Item 14

Enter the date on which the informal dispute resolution process ended.

Item 15

If applicable, insert the date on which the facility is terminated. This date cannot be later

than six months after the date of survey.

Item 16 Indicate by inserting a “Y” if an allegation of compliance was received from the facility. Field

should be left blank if no allegation of compliance is received.

Item 17 Indicate the entity (CMS or the Medicaid State Agency) which is taking the enforcement

action (i.e., imposing the remedy or remedies).

Item 18 Indicate whether the facility requested an appeal of the determination of noncompliance

made by CMS or the Medicaid State Agency.

Item 19

Indicate if the facility’s approval for its nurse aide training program was rescinded.

Item 20

Insert the code (01 – 11) for each remedy proposed for imposition against the facility.

Item 21

Insert the proposed effective date of each remedy.

Item 22 Insert the proposed civil money penalty amount in whole dollars per day if the remedy

recorded on the corresponding field is a civil money penalty (type 07).

Item 23 Insert the revision code for each of the corresponding remedies, if applicable. Use the

revision code “M” if the corresponding remedy, proposed effective date, or proposed civil

money penalty amount in item #20, #21, or #22, respectively, was changed per decision

of the Medicaid State Agency. Likewise, enter code “R” if the corresponding remedy,

proposed effective date, or proposed civil money penalty amount in item #20, #21, or #22,

respectively, was changed per decision of the CMS RO.

Item 24 Insert the actual effective date for each of the remedies inserted in item 20. This field is

completed even if there is no revision code entered in item #23.

Item 25 Insert the corresponding end date for each of the remedies inserted in item 20. This date

cannot be later than six months after the date of survey.

Item 26 If a civil money penalty is imposed, enter the whole dollar amount of any adjusted daily

amounts subsequent to the effective date of the proposed amount (see item #22). A civil

money penalty is imposed in $50 increments in accordance with the procedures at section

7516 of the State Operations Manual and the regulations at §488.438, and may be adjusted

to reflect an increase or decrease according to the regulations cited above. An example of

an upward adjustment would be an increase in the penalty amount due to the emergence

of an immediate jeopardy situation or repeat deficiencies. An example of a downward

adjustment is the reduction of the penalty amount because of the removal of an immediate

jeopardy situation. If there is no adjustment in penalty, leave this field blank.

Enter the date the total amount is due. The total amount should reflect one of the following:

the full amount of the penalty imposed; the amount determined to be owed after the facility

waives its right to a hearing according to the procedures at section 7526 of the State

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

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Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs Page 4

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