The certification kit format provides ready access to all certification-related forms for the supported provider types. The forms screens correspond as closely as possible to the CMS forms and instructions used in the field, except they do not capture provider and surveyor information that is collected
elsewhere in ASPEN.
Enter CMS-670 Data
Initial certification and recertification surveys are sometimes conducted in combination with other surveys. ASPEN provides a single screen where you can enter all survey hours broken down by survey type. Only those hours attributed to the certification survey will be uploaded with the certification kit.
If state licensure survey(s): State Licensure, Initial Licensure, Re-Licensure, and Licensure Complaint are combined with a Federal initial certification or recertification survey (or complaint/incident investigation/survey), the corresponding Licensure row(s) in the CMS-670 grid are disabled due to existing CMS-670 guidelines. Licensure rows are, however, enabled for state licensure surveys of federally certified providers that are not combined with a Federal initial certification or recertification survey (or complaint/incident investigation/survey).
1 Scroll to the Survey List section on the Certification & Surveys tab of the Certification window.
Survey List on page 147
2 Select a survey and click
The CMS 670 Workload Detail window lists all surveyors on the roster, with rows for each survey type. Survey dates and types are brought forward from the Survey Properties window.
CMS 670 Workload Detail window on page 196
3 Select the Lead checkbox to indicate the survey team leader.
4 Select or de-select On Team as appropriate for survey team members.
The On Team checkbox is selected by default for all team members and all survey types.
5 Enter hours for each staff member and survey type, as appropriate.
Print CMS-2567
6 Click to enter supervisory and clerical hours for each survey type; click when you are done.
You will receive overridable messages if you do not enter all required office hours.
7 Click at the bottom of the CMS 670 Workload Detail window to print the CMS-670 form.
8 Click to close the CMS 670 Workload Detail window.
You will receive overridable messages if you haven’t entered all required hours.
1 Scroll to the Survey List section on the Certification & Surveys tab of the Certification window.
Survey List on page 147
2 Select a survey and click
3 In the Select Forms to print window, select the checkbox for CMS 2567 or 2567B (for revisits), and click
4 In the Customize Survey Report Form window, select the options you want:
• Include Surveyor ID Numbers prints the ID numbers of survey team members.
• Include Severity and Scope Data includes the SS code for each tag.
Depending on provider type, this option may or may not be selected by default. For example, it is selected for NHs, but not for labs.
• Include Tag 9999 prints Tag 9999 comments.
• Include Team List on Last Page includes the survey team roster on the last page of the form.
• Include POC Text prints the Plan of Correction.
• Only Active Surveyor’s Info includes only the active surveyor’s citations on the form.
• Use Original Name prints the form using the provider’s prior name.
• Use Large Font prints the form in a larger font size.
• Print Instructions includes the Instructions for Completion of the CMS-2567 form as the cover page.
Enter CMS-1539 Data
You enter certification and transmittal information on the Transmittal
(CMS-1539) tab of the Certification window. Multiple CMS-1539s can exist in cases of followup surveys that occur before scheduled submissions or when there is a change in correction dates. CMS-1539 C&T information can be updated prior to each submission to OSCAR.
Note: The Transmittal (CMS-1539) tab does not appear when you display the Certification window for certification kits with a Prior status.
5 To include more than one survey type, regulation set, or building on the same form, click
If the survey contains multiple regulation sets (or buildings if LSC), ASPEN normally produces a separate CMS-2567 for each one. Use the Combine function to combine regulations or buildings on one form. You cannot, however, combine Federal and state regulations on the same form.
6 In the Specifications for Combined Survey Report Form window, select the items you want to include on your form.
7 Click to return to the previous window.
8 Click to print the form.
Citations with a scope and severity of 1/1 (A) designated in Citation Properties print only on the CMS-2567A form. If your survey has such a citation, you can choose to print the CMS-2567L, the CMS-2567A, or both.
NH only - PNC tags are printed on the 2567, but not the 2567B. If there are PNC tags, the following message appears in the Provider's Plan of Correction column: “Past noncompliance: no plan of correction required.”
1 Click the Transmittal (CMS-1539) tab in the Certification window.
2 SA - Enter provider and program participation information in Part I.
CMS-1539 - Part I on page 150
Note: Fields that do not apply to the current provider type either are disabled or are not displayed.
• Effective Date: Change of Ownership (L9) - disabled for initial certification kits that have not been accepted by OSCAR.
• Type of Action (L8) - enabled only for recertification kits that have not been accepted by OSCAR. If there are no prior kits, L8 is set to Initial and cannot be changed.
• Accreditation Status (L10) - enabled for providers that can be accredited or deemed. Select the applicable accrediting agency.
• Deemed? - enabled only if an accepted accrediting agency is selected in L10.
Hospitals are automatically deemed if they are accredited, so when an accrediting organization is specified for a Hospital in L10, Deemed? is set to Yes and locked.
HHA, ASC, and Hospice providers are not necessarily deemed if accredited, so for them L10 and Deemed? operate independently.
• Fiscal Year Ending Date (L35) - use the format MM/DD, e.g., 02/04.
ASPEN provides the “/”.
• Total Facility Beds (L18) - enter the number.
• Total Certified Beds (L17) - calculated by the system as L37+L38+L39.
• Certified As section (L12)
If the provider is In Compliance, you must also select what the compliance is Based On from the options in the list box.
If you select In Compliance but don’t indicate the basis, Code A will appear in the L12 field when you generate the CMS-1539 form. If you indicate the basis, the code on the form reflects this. For example, if you select 1- Acceptable POC and 9 - Beds Per Room, Code A19 will appear in the L12 field.
• LTC Certified Beds L37, L38, L39, and L43 - enter numbers; enabled as applicable. If you change bed numbers in a certification kit that has already been uploaded, first select the provider type from the Type drop-down to enable the applicable bed fields. The changes are sent to OSCAR as an implicit transaction, i.e., without another upload.
• Click to add, modify, or delete bed summaries. Numbers in the Beds window are not automatically transferred to the CMS-1539 beds fields.
• Facility Meets - select the appropriate option.
• State Remarks - use field 30 at the bottom of the window.
If the remarks are brief, they will appear in field 16 on the form; if they are long, they will be in field 30.
• Surveyor Sign Date (L19) and State Agency Approval date (L20) - enter or select these dates.
3 RO or SSA - Enter administrative
information in Part II. CMS-1539 - Part II on page 151
• Eligible to Participate (L21) - Yes or No.
• Original Date of Participation (L24) - enter for initial certifications.
Enabled in ARO; enabled only for NF, Medicaid HHA, and ICF/MR providers in ACO. The date is stored in OSCAR and supplied by the system for recertifications.
• LTC Agreement Beginning (L41) - enter or select this date. Enabled for ICF/MR only.
• LTC Agreement Ending (L25) - enter or select this date. Enabled for ICF/MR only.
• Select the Termination Code (L30) - enabled in ARO; enabled only for NF, Medicaid HHA providers, and ICF/MR providers in ACO. Not enabled for initial certification kits that have not been accepted by OSCAR.
• LTC Extension Date (L27) - enter or select this date. Enabled for ICF/MR only.
• Alternative Sanction L44 and L45 - Enter or select these dates. Enabled for ICF/MR only.
• Termination Date (L28) - enter or select if Termination Code (L30) is anything other than 00 Active.
• Intermediary/Carrier No. (L31) - disabled for NF, Medicaid HHA and ICF/MR providers.
• RO Receipt Date (L32) - enabled in ARO. L32 is never required for NF, Medicaid HHA, and ICF/MR providers. It is required for Medicare HHA 05 and SNF 02, 03, 04. ASPEN generates this date when the kit is uploaded.
• RO Analyst - enter initials.
• Determination Approval date (L33) - enabled in ARO; enabled only for NF, Medicaid HHA, and ICF/MR providers in ACO. When you upload an unflagged recertification, ASPEN attempts to insert the date of the upload if this field is blank. It can also be entered manually. It must be entered manually for other certification types.
• RO Final Rev[iew] Date # (SF15) - enabled in ARO only if L32 is entered for NF, Medicaid HHA, or ICF/MR providers. The final review date must be greater than or equal to L32.
• Remarks - if the remarks are brief, they will appear in field 16 on the form; if they are long, they will be in field 30.
4 Click at the bottom of the window to print the CMS-1539 form.
Enter Application Worksheet Data - HOSPITAL
The Application Worksheet tab captures information about a Hospital provider such as accreditation dates, staffing, services, off-site locations–just to name a few.
Note: The Application Worksheet tab does not appear when you display the Certification window for certification kits with a Prior status.
Enter CMS-2786 Data - NH
Use the LSC 2786 (K9) tab to enter and print fire safety survey information for NHs and ICF/MRs, and optionally for ASCs and Hospices.
1 Click the Application Worksheet tab in the Certification window.
2 Complete required and
applicable fields in the various sections of the Worksheet:
Hospital Application Worksheet on page 151
• Accreditation and CLIAs
• Control and Resident Programs
• General Information
• Number of Employees
• Type of Reimbursement or Status
• Services Provided
• Sprinkler Status
• Off-site locations
• Affiliated providers
1 Scroll to the Survey List section on the Certification & Surveys tab of the Certification window.
Survey List on page 147
2 Click the LSC 2786 (K9) tab. LSC 2786 (K9) tab on page 148 3 As applicable, enter compliance information directly on the grid.
4 Click to generate the form.
Enter CMS-671 Data
You enter LTC Medicare/Medicaid application information on the Application (CMS-671) tab of the Certification window.
Note: The Application (CMS-671) tab does not appear when you display the Certification window for certification kits with a Prior status.
1 Click the Application (CMS-671) tab in the Certification window.
2 Enter general provider
information in the top section. CMS-671 - General Provider Information on page 156
• Standard Survey From (F1) - start date of the standard Health survey, supplied by the system.
• [Standard Survey] To date (F2) - cannot be later than the exit date of the standard Health survey.
• Extended Survey From (F3) - must be later than or equal to Standard Survey From (F1); cannot be later than [Extended Survey] To (F4).
• [Extended Survey] To (F4) - must be later than F3. If you enter a date in F3, you must enter a date in F4.
• Program Participation (F9) - supplied by the system based on provider type.
• Is this facility hospital based? F10 - Yes or No.
• Hospital Provider Number F11 - enter if F10 is Yes. Either type the Hospital’s 6-digit Medicare provider number, or use to locate and insert the number.
• Ownership (F12) - select type from the drop-down list.
• Optionally click to add, assign, modify, or delete owner companies. Information entered in the Owners window is not automatically transferred to certification forms.
• Owned or leased by Multi-Facility Organization? (F13) - Yes or No.
• Name of Multi-Facility Organization (F14) - enter if F13 is Yes.
• Dedicated Special Care Units (F15-F23) - enter the number of beds that have been dedicated by the provider to the applicable types of special care.
• F24-F27 - respond Yes or No to these questions about provider services: organized groups, research, CCRC affiliation.
• Date (F28, F30) - if the provider has been granted a waiver of the seven day RN and/or 24 hour licensed nursing requirement, enter the Date of the waiver.
Enter CMS-672 Data - NH
CMS-672 provides a snapshot of the resident population at the time of the survey.
Note: The Census (CMS-672) tab does not appear when you display the Certification window for certification kits with a Prior status.
• Hours waived per week? (F29, F31) - enter if either or both waivers have been granted.
• Approved Nurse Aide Training and Competency Evaluation Program (F32) - Yes or No.
• Feeding assistant program - Yes or No. This field can be left blank.
3 Enter provider staffing information in the bottom section.
CMS-671 - Facility Staffing on page 157
• Select a checkbox in any or all of columns A1, A2, and A3 as applicable for each service provided.
• If you select A1 or A3 (to indicate the service is provided to facility residents), enter the corresponding hours of service providers in any or all of columns B, C, and D as applicable.
4 Click at the bottom of the window to print the CMS-671 form.
1 Click the Census (CMS-672) tab in the Certification window.
2 Enter required resident census
data in the top section. CMS-672 - Resident Census on page 158
• Provider Number - supplied by the system; taken from the Facility Definition window.
• Medicare (F75), Medicaid (F76), and Other (F77) - enter the number of residents in the facility on the day the survey begins. These fields are enabled according to the facility’s type and program participation.
• Total Residents (F78) - calculated by the system from F75, F76, and F77.
• ADL (Activities of Daily Living) section - indicate the level of assistance needed by residents for the listed activities (F79-F93). The number of residents recorded for each activity must equal Total Residents (F78).
ASPEN calculates Totals for each activity.
Enter CMS-1572A Data - HHA
When the HHA application for certification is received from the provider, you can enter application (survey and deficiencies) information for the provider on the Application (CMS-1572A) tab.
Note: The Application (CMS-1572A) tab does not appear when you display the Certification window for certification kits with a Prior status
3 Enter resident condition data in
sections A-G. CMS-672 - Conditions of Residents on page 159
• A. Bowel/Bladder Status - enter the number of residents with the specified bowel/bladder conditions in F94-F99.
• B. Mobility - enter the number of residents with the specified levels of mobility in F100-F107.
• C. Mental Status - enter the number of residents with the specified mental conditions in F108-F114.
• D. Skin Integrity - enter the number of residents with the specified skin conditions in F115-F118.
• E. Special Care - enter the number of residents receiving the specified special care in F119-F132.
• F. Medications - enter the number of residents receiving the specified medications in F133-F139.
• G. Other - enter the number of residents with other specified conditions in F140-F145.
4 Complete several miscellaneous
items at the bottom of the form. CMS-672 - Miscellaneous on page 160
• Ombudsman notified (F146) - select if the ombudsman’s office was notified prior to the survey.
• Ombudsman present (F147) - select if the ombudsman was present during any part of the survey.
• Medication Error Rate (F148) - enter the rate at the time of survey, as observed by the surveyor.
5 Click at the bottom of the window to print the CMS-672 form.
1 Click the Application (CMS-1572A) tab in the Certification window.
2 Complete several required items in the Description section at the
top of the form. CMS-1572A - Description on page 161
Read-only provider identification information in this section is derived from the ACO database.
• Type of Survey - select the Initial (G2) type for initial certification, or Resurvey (G3) type for recertification.
• Eligibility (G7) - select an option.
• CHOW Since Last Survey? (G9) - enabled only for recertifications;
select if applicable.
3 Enter information about the provider’s administration and affiliations in the next section.
CMS-1572A - Administration and Affiliations on page 162
• Administrator (G8) - select the administrator’s occupation from the drop-down list.
• Optionally click to open the Administration window;
select and assign the administrator.
The primary administrator is listed in the Administrator section.
If you access the Administration window outside the certification kit, the information is not automatically transferred to the kit.
• Hospice (G10) - select the Is Agency also a Hospice? checkbox and enter the Medicare ID (G11) directly; or click and in the Find Related hospice window, search for the Hospice, select it and click Return Selection to supply the Medicare ID (G11).
If the Medicare ID of the Hospice contains more than six characters, it is truncated in G11 on the Application (CMS-1572A) tab.
• Agency Operates Sub-units (G12) - select the Agency has Sub-units?
checkbox and enter # of Sub-units (G13) directly; or optionally click to open the Define Subunits window. Click
and enter details in the Facility Relationship Manager window. Click in both windows to return to the Application (CMS-1572A) tab. The # of Sub-units field (G13) is incremented by 1.
• Sub-unit or Other Provider (G14) - enter the Parent Medicare # (G15) directly; or select the Agency is a Sub-unit? checkbox and
click to open the Find Parent Agency window. Search for the parent agency, select it, and click Return Selection to supply the Parent Medicare # (G15).
A provider cannot both be a sub-unit and have sub-units.
• Branch Offices (G16) - select the Has Branches? checkbox and enter number of Branches (G17) directly. Click to enter details about a branch in the Facility Relationship Manager window.
Click to add the branch to the Branch Offices grid.
• Agency Type (G18), Control Type (G20) - select from the drop-down lists.
• Provider Number (G19) - enter if applicable. This field is enabled for Agency Types (G18) that are followed by an asterisk * To locate the provider number for the agency, click Find.
If the Provider Number contains more than six characters, it is truncated on the Application (CMS-1572A) tab.
4 Enter information about services
and staffing in the third section. CMS-1572A - Services and Staffing on page 162
Note: Services entered here are specific to the CMS-1572A. They are not included in the Services node for the provider in the Tree view.
• Services Offered (G21) - select the appropriate option for each.
Nursing Care (01) and at least one other of Physical Therapy (02), Occupational Therapy (03), Speech Therapy (04), Medical Social Worker (05), or Home Health Aide (06) must be offered for the application to be complete.
• Staffing (G22-G31) - enter number of staff for each selected Service (G21).
A significant increase or decrease in total staff will trigger an error message. Review all staffing numbers to ensure the information is accurate. If it is, select the Staff Override (SF12) checkbox on the Certification & Surveys tab.
• HHA Provides Directly(G32) - select the appropriate option.
5 Enter record review and patient census data, and complete all other required fields in the fourth section.
CMS-1572A - Visits, Census, Other on page 163
• Record Review (G33-G37) - enter the number of home visits and records reviewed.
• Patient Census (G38-G44) - enter Admissions and Discharges data.
• Surveyor Summary (G45) - select the appropriate option.
• Survey Frequency - select the appropriate option.
• HHA Qualified for OPT (Outpatient Physical Therapy) - Yes or No.
Enter CMS-1880 Data - XRAY
You enter application information for portable X-ray suppliers on the Application (CMS-1880) tab of the Certification window.
Note: The Application (CMS-1880) tab does not appear when you display the Certification window for certification kits with a Prior status.
Enter CMS-1856/1893E Data - OPT/SP
You enter application information for Outpatient Physical/Speech Therapy providers on the App/CDE (CMS-1856/1893E) tab of the Certification window.
Note: The App/CDE (CMS-1856/1893E) tab does not appear when you display the Certification window for certification kits with a Prior status.
6 Click at the bottom of the window to print the CMS-1572 form.
1 Click the Application (CMS-1880)
tab in the Certification window. XRAY Application (CMS-1880) on page 166
2 Select the program for which the provider is applying from the Request to Establish Eligibility In (S22) drop-down.
2 Select the program for which the provider is applying from the Request to Establish Eligibility In (S22) drop-down.