WHAT IS A CONDITION-LEVEL DEFICIENCY?If a hospital receives a CMS Termination Letter, it means that CMS has

determined that the hospital has a condition-level deficiency, indicating

the hospital is not in substantial compliance with one or more of the

Centers of Medicare and Medicaid Services (CMS) Conditions of

Participation (CoPs). Hospitals must be in compliance with all CoPs to

participate in the Medicare program.

CMS TERMINATION LETTERWHAT TO EXPECT AND HOW TO PREPARE

When condition-level deficiencies are discovered, the CMS will issue a

Statement of Deficiencies (Form CMS-2567) and an enforcement letter that

outlines the conditions that are out of compliance, whether the hospital is on a

termination track due to condition-level noncompliance, and the date the

hospital is expected to return to compliance. It will also let the hospital know

what information needs to be in the hospital’s credible allegation of

compliance (also known as the Plan of Correction).

THE ENFORCEMENT LETTER

If the CMS determines an organization’s non-compliance has or could cause

serious injury/harm/impairment/death, it initiates an enforcement action and

requires the provider to remove the immediate jeopardy with swift interim

actions (which will then convert the termination to a 90-day track). If the

jeopardy is not removed within 23 calendar days, the provider is terminated from

the Medicare/Medicaid programs.

If there is no immediate jeopardy, the CMS issues a preliminary notice that the

provider agreement will be terminated in 90 days if the hospital does not

either correct or refute the identified deficiencies.

ACTIONS TO BE TAKENIn the enforcement letter, the CMS will outline two types of adverse actions

that can be taken:

5 CRITICAL ACTIONS TO TAKE IF YOU RECEIVE A CMS TERMINATION LETTER

THE PLAN OF CORRECTION (POC)

Hospitals that receive a Statement of Deficiencies with Notice of

Immediate Jeopardy or Notice of Termination have 10 days to prepare

and submit a formal written response, or POC, which identifies the steps

they will take or have taken to resolve the issues. The POC must clearly

define the steps and time frame in which the hospital will remove the

deficient practice and achieve compliance with the regulations.

After receiving and accepting the hospital’s POC and re-surveying to

evaluate compliance, CMS may either:

Clear the termination. Authorize a second

survey and extend the

termination date.

Notify the hospital by

letter of its intent to

terminate participation

in the Medicare/

Medicaid program (at

least 15 days before

the termination date).

1. Make sure you’re

aware of all critical dates.

2. Do not overcommit on

changes or implement

processes that cannot

be sustained.

3. Focus your POC on

addressing the “big

issues:” where the

process failed, whether

it was an isolated

incident or a pattern, etc.

4. Uncover and correct

underlying issues,

including poor

understanding of CoPs,

a weak compliance

process or a poorly

designed policy.

5. Beware of closely

nested standards in

the same condition

that was cited.

NOTICE OF IMMEDIATE JEOPARDY

NOTICE OF TERMINATION, ADVERSE ACTION

POC