Form Cms-462l - Adverse Acti0n Extract For Snfs And Nfs Page 5

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Operations Manual and the regulations at §488.436; the amount set forth in a hearing
decision.
Enter the date that the total amount of the civil money penalty is paid.
Part 2
(To be completed only if the facility requests a hearing)
Item 27
Enter the date CMS receives an administrative appeal from the facility.
Item 28
Enter the date the decision by the Administrative Law Judge (ALJ) is rendered.
Item 29 Enter the status of CMS’s determination of noncompliance as per the ALJ’s decision
(“R” for reversed, “S” for sustained, “M” for modified).
Item 30
If applicable, enter the date the Departmental Appeals Board (DAB) renders its decision.
Item 31 Enter the status of CMS’s determination of noncompliance as per the DAB’s decision
(“R” for reversed, “S” for sustained, “M” for modified).
Item 32
If the facility files an appeal in U.S. District Court, enter the date the appeal is filed.
Item 33
Enter the date the U.S. District Court renders its decision.
Item 34 Enter the status of CMS’s determination of noncompliance as per the U.S. District Court’s
decision (“R” for reversed, “S” for sustained, “M” for modified).
Item 35 If the facility files an appeal in the U.S. Circuit Court of Appeals, enter the date the appeal
is filed.
Item 36
Enter the date the U.S. Circuit Court of Appeals renders its decision.
Item 37 Enter the status of CMS’s determination of noncompliance as per the U.S. Circuit Court of
Appeals decision (“R” for reversed, “S” for sustained, “M” for modified).
Item 38 If the facility files an administrative appeal with the State, enter the date the appeal was
received. NOTE: Only Medicaid facilities may file appeals with the State.
Item 39
Enter the date the State renders the decision of the administrative appeal.
Item 40 Enter the status of the State’s determination of noncompliance as per the administrative
decision (“R” for reversed, “S” for sustained, “M” for modified).
Item 41
If the facility files an appeal in the State District Court, enter the date the appeal is filed.
Item 42
Enter the date the State District Court renders its decision.
Item 43 Enter the status of the State’s determination of noncompliance as per the State district court’s
decision (“R” for reversed, “S” for sustained, “M” for modified).
Item 44
If the facility files an appeal in the State Court of Appeals, enter the date the appeal is filed.
Item 45
Enter the date the State court of appeals renders its decision.
INSTR. to FORM CMS-462L (7/95)
Page 3 of 4

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