Cms-1539 - Centers For Medicare & Medicaid Services

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
PART 1—TO BE COMPLETED BY STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
3. NAME AND ADDRESS OF FACILITY
4. TYPE OF ACTION:
L3
1. INITIAL SURVEY
L1
2. RECERTIFICATION
3. TERMINATION
2. STATE VENDOR OR MEDICAID NO.
L4
4. CHOW
STATE
5. VALIDATION
6. COMPLAINT
L2
L5
L6
7. ON SITE VISIT
5. EFFECTIVE DATE FOR CHANGE OF OWNERSHIP
7. PROVIDER/SUPPLIER CATEGORY
8. TERMINATION OF ICF BEDS
9. OTHER
01 HOSPITAL
04 SNF
09 ESRD
14 CORF
02 SNF/ICF
05 HHA
10 ICF
15 ASC
M
M
D
D
Y
Y
L9
(DUALLY
L8
06 LAB
11 IMR
16 HOSPICE
6. DATE OF SURVEY
CERTIFIED)
9. FISCAL YEAR ENDING DATE
03 SNF/ICF
07 X-RAY
12 RHC
(DISTINCT
08 OPT/SF
13 PTIP
PART)
L
M
M
D
D
Y
Y
34
L7
M
M
D
D
L35
8. ACCREDITATION STATUS
10. THE FACILITY IS CERTIFIED AS:
0 UNACCREDITED
1 JCAHO
A. IN COMPLIANCE WITH
AND/OR APPROVED WAIVERS OF THE FOLLOWING
2 AOA
3 OTHER
PROGRAM REOUIREMENTS
REQUIREMENTS:
L10
11. LTC PERIOD OF CERTIFICATION
COMPLIANCE BASED ON:
1 - ACCEPTABLE POC
2 - TECHNICAL
6 - SCOPE OF
(a) From
PERSONNEL
SERVICE LIMITED
(b) To
B. NOT IN COMPLIANCE WITH
7 - MEDICAL
3 - 24HR RN
M
M
D
D
Y
Y
PROGRAM REQUIREMENTS
DIRECTOR
AND/OR APPLIED WAIVERS:
12. TOTAL FACILITY BEDS
4 - 7-DAY RN
8 - PATIENT ROOM
(RURAL SNF)
L18
13. TOTAL CERTIFIED BEDS
A/B
5 - LIFE SAFETY
9 - BEDS PER
(IF APPLICABLE CODES 1-9)
CODE
-ROOM
L17
L12
14. LTC
15. FACILITY MEETS
F. SNF/ICF
CERT.
A 18 SNF
B. 18/19 SNF
C. 19 SNF
D. ICF
E. IMR
DUALLY CERT.
1861(e)(1) or 1861(j)(1)
BED
1 - YES
BREAK
2 - NO
DOWN
L37
L38
L39
L42
L43
L40
L15
16. STATE SURVEY AGENCY REMARKS
(IF APPLICABLE SHOW LTC CANCELLATION DATE IN REMARKS)
17. SURVEYOR SIGNATURE
18. STATE SURVEY AGENCY APPROVAL
M
M
D
D
Y
Y
M
M
D
D
Y
Y
L19
L20
PART II—TO BE COMPLETED BY CMS REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
20. COMPLIANCE WITH
21. 1 - STATEMENT OF FINANCIAL SOLVENCY (CMS-2572)
CIVIL RIGHTS ACT
2 - OWNERSHIP AND CONTROL INTEREST
1 - FACILITY IS ELIGIBLE TO PARTICIPATE
DISCLOSURE STATEMENT (CMS 1513)
2 - FACILITY IS NOT ELIGIBLE TO PARTICIPATE
3 - BOTH OF THE ABOVE
L21
22. ORIGINAL DATE
23. LTC AGREEMENT
24. LTC AGREEMENT
26.TERMINATION ACTION
OF PARTICIPATION
BEGINNING DATE
ENDING DATE
VOLUNTARY
INVOLUNTARY
1 - MERGER, CLOSURE
5 - FAILURE TO MEET
HEALTH/SAFETY
2 - DISSATISFACTION
M
M
D
D
Y
Y
M
M
D
D
Y
Y
M
M
D
D
Y
Y
WITH REIMBURSEMENT
6 - FAILURE TO MEET
L24
L41
L25
AGREEMENT
3 - RISK OF INVOLUNTARY
25. LTC EXTENSION
27. ALTERNATIVE SANCTIONS
TERMINATION
DATE
OTHER
A. SUSPENSION OF ADMISSIONS
B. RESCIND SUSPENSION DATE
4 - OTHER REASON
7 - PROVIDER STATUS
FOR WITHDRAWAL
CHANGE
M
M
D
D
Y
Y
M
M
D
D
Y
Y
M
M
D
D
Y
Y
L30
L27
L44
L45
28. TERMINATION DATE
29. INTERMEDIARY/CARRIER NO.
30. REMARKS
M
M
D
D
Y
Y
L28
L31
31. RO RECEIPT OF CMS-1539
32. DETERMINATION APPROVAL DATE
DETERMINATION APPROVAL
M
M
D
D
Y
Y
M
M
D
D
Y
Y
L32
L33
FORM CMS-1539 (07/84)

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