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Note: The CMS 2567 is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the SA notices any discrepancy in the information, the Regional Office will make a referral of possible fraud to the Office of the Inspector General (OIG).
An unannounced visit was made to conduct a follow-up and complaint survey per Sections 5040, 5130 and 5210F of the State Operations Manual (SOM). Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals was utilized to determined hospital's compliance with 42 CFR 482 Conditions of Participation (CoP) for Hospitals. An entrance conference was held on the morning of 04-04-17 with key administrative personnel. The purpose, scope and process of the survey was explained and an opportunity for questions and discussion was provided.
An exit conference was held on the afternoon of 04-07-17 with key administrative personnel. The preliminary findings of the survey were discussed and again, an opportunity for questions and discussion was provided. The facility Chief Executive Officer and the owner were informed on 04-07-17 at 3:00 p.m. that the Immediate Jeopardy could not be removed due to the current findings. The following Conditions of Participation were determined to remain out of compliance:
42 CFR 482.12 Governing Body
42 CFR 482.13 Patient Rights
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