42 C.F.R. Subpart C—Certification of ICFs/MR
Title 42 - Public Health
A State plan must provide that the requirements of this subpart and part 483 are met. [53 FR 20495, June 3, 1988] (a) This section states the requirements for obtaining notice of an ICF/MR's certification before a Medicaid agency executes a provider agreement under §442.12. (b) The agency must obtain notice of certification from the Secretary for an ICF/MR located on an Indian reservation. (c) The agency must obtain notice of certification from the survey agency for all other ICFs/MR. (d) The notice must indicate that one of the following provisions pertains to the ICF/MR: (1) An ICF/MR meets the conditions of participation set forth in subpart I of part 483 of this chapter. (2) The ICF/MR has been granted a waiver or variance by CMS or the survey agency under subpart I of part 483 of this chapter. (3) An ICF/MR has been certified with standard-level deficiencies and (i) All conditions of participation are found met; and (ii) The facility submits an acceptable plan of correction covering the remaining deficiencies, subject to other limitations specified in §442.105. (e) The failure to meet one or more of the applicable conditions of participation is cause for termination or non-renewal of the ICF/MR provider agreement. [56 FR 48866, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 59 FR 56236, Nov. 10, 1994] If a survey agency finds a facility deficient in meeting the standards for ICFs/MR, as specified under subpart I of part 483 of this chapter, the agency may certify the facility for Medicaid purposes under the following conditions: (a) The agency finds that the facility's deficiencies, individually or in combination, do not jeopardize the patient's health and safety, nor seriously limit the facility's capacity to give adequate care. (b) The agency finds acceptable the facility's written plan for correcting the deficiencies. (c) If a facility was previously certified with a deficiency and has a different deficiency at the time of the next survey, the agency documents that the facility— (1) Was unable to stay in compliance with the standard for ICFs/MR for reasons beyond its control, or despite intensive efforts to comply; and (2) Is making the best use of its resources to furnish adequate care. (d) If a facility has the same deficiency it had under the prior certification, the agency documents that the facility— (1) Did achieve compliance with the standard for ICFs/MR at some time during the prior certification period; (2) Made a good faith effort, as judged by the survey agency, to stay in compliance; and (3) Again became out of compliance for reasons beyond its control. [56 FR 48866, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 57 FR 54712, Nov. 20, 1992; 59 FR 56236, Nov. 10, 1994] (a) A survey agency may certify a facility that fully meets applicable requirements for up to 12 months. (b) The survey agency may notify the Medicaid agency that the term of a provider agreement may be extended up to 2 months after the expiration date of the agreement under the conditions specified in §442.16. [43 FR 45233, Sept. 29, 1978. Redesignated at 53 FR 1993, Jan. 25, 1988, and amended at 59 FR 56236, Nov. 10, 1994] (a) Facilities with deficiencies may be certified under §442.105 for the period specified in either paragraph (b) or (c) of this section. (b) The survey agency may certify a facility for a period that ends no later than 60 days after the last day specified in the plan for correcting deficiencies. The certification period must not exceed 12 months, including the period allowed for corrections. (c) The survey agency may certify a facility for up to 12 months with a condition that the certification will be automatically canceled on a specified date within the certification period unless— (1) The survey agency finds that all deficiencies have been satisfactorily corrected; or (2) The survey agency finds and notifies the Medicaid agency that the facility has made substantial progress in correcting the deficiencies and has a new plan for correction that is acceptable. The automatic cancellation date must be no later than 60 days after the last day specified in the plan for correction of deficiencies under §442.105. [43 FR 45233, Sept. 29, 1978. Redesignated and amended at 53 FR 1993, Jan. 25, 1988; 59 FR 56236, Nov. 10, 1994] (a) A survey agency must terminate a facility's certification if it determines that— (1) The facility no longer meets conditions of participation for ICFs/MR as specified in subpart I of part 483 of this chapter. (2) The facility's deficiencies pose immediate jeopardy to residents' health and safety. (b) Subsequent to a certification of a facility's noncompliance, the Medicaid agency must, in terminating the provider agreement, follow the appeals process specified in part 431, subpart D of this chapter. [51 FR 24491, July 3, 1986, as amended at 59 FR 56236, Nov. 10, 1994] (a) Basis for denial of payments. The Medicaid agency may deny payment for new admissions to an ICF/MR that no longer meets the applicable conditions of participation specified under subpart I of part 483 of this chapter. (b) Agency procedures. Before denying payments for new admissions, the Medicaid agency must comply with the following requirements: (1) Provide the facility up to 60 days to correct the cited deficiencies and comply with conditions of participation for ICFs/MR. (2) If at the end of the specified period the facility has not achieved compliance, give the facility notice of intent to deny payment for new admissions, and opportunity for an informal hearing. (3) If the facility requests a hearing, provide an informal hearing that includes— (i) The opportunity for the facility to present, before a State Medicaid official who was not involved in making the initial determination, evidence or documentation, in writing or in person, to refute the decision that the facility is out of compliance with the conditions of participation for ICFs/MR. (ii) A written decision setting forth the factual and legal bases pertinent to a resolution of the dispute. (4) If the decision of the informal hearing is to deny payments for new admissions, provide the facility and the public, at least 15 days before the effective date of the sanction, with a notice that includes the effective date and the reasons for the denial of payments. [51 FR 24491, July 3, 1986, as amended at 59 FR 56236, Nov. 10, 1994] (a) Period of denial. The denial of payments for new admissions will continue for 11 months after the month it was imposed unless, before the end of that period, the Medicaid agency finds that— (1) The facility has corrected the deficiencies or is making a good faith effort to achieve compliance with the conditions of participation for ICFs/MR; or (2) The deficiencies are such that it is necessary to terminate the facility's provider agreement. (b) Subsequent termination. The Medicaid agency must terminate a facility's provider agreement— (1) Upon the agency's finding that the facility has been unable to achieve compliance with the conditions of participation for ICFs/MR during the period that payments for new admissions have been denied; (2) Effective the day following the last day of the denial of payments period; and (3) In accordance with the procedures for appeal of terminations set forth in subpart D of part 431 of this chapter. [51 FR 24491, July 3, 1986, as amended at 59 FR 56236, Nov. 10, 1994]
Title 42: Public Health
PART 442—STANDARDS FOR PAYMENT TO NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED
Subpart C—Certification of ICFs/MR
§ 442.100 State plan requirements.
§ 442.101 Obtaining certification.
§ 442.105 Certification of ICFs/MR with deficiencies: General provisions.
§ 442.109 Certification period for ICFs/MR: General provisions.
§ 442.110 Certification period for ICFs/MR with standard-level deficiencies.
§ 442.117 Termination of certification for ICFs/MR whose deficiencies pose immediate jeopardy.
§ 442.118 Denial of payments for new admissions to an ICF/MR.
§ 442.119 Duration of denial of payments and subsequent termination of an ICF/MR.
