Documentation Definitions

Question 1

COP

Answer 1

“Condition of Participation” are requirements with which an entity must comply in order to participate in the programs. Also refers to “Condition for Coverage” relevant to suppliers.

Question 2

Deficiency Citation

Answer 2

An entry made on the form CMS-2567 that includes

1. The alpha prefix and data tag number
2. Code of Federal Regulations (CFR) or Life Safety Code (LSC
3. Language from that reference which pinpoints the aspects of the requirement wiht which the entity failed to comply
4. An explicit statement that the requirement was “NOT MET”
5. Evidence (the deficient entity practice statement and relevant individual findings or facts) to support the decision of noncompliance.

Question 3

Deficient Practice

Answer 3

Actions, errors or lack of action on the part of the entity relative to a requirement (and to the wxtent possible, the resulting outcome).

Question 4

Deficient Practice Statement

Answer 4

Statement at the beginning of the evidence that sets out why the entity was not in compliance with a regulation

Question 5

Entity

Answer 5

Generic term used to describe providers and suppliers under the Social Security Act or laboratories that participate in the CLIA program

Question 6

Evidence

Answer 6

an integral part of the citation that begins with a description of the deficient entity practice and identifies the relevant individual findings and facts that substantiate the failure of the entity to comply with the regulation.

Question 7

Extent

Answer 7

of deficient practice- the prevalence or frquency of a deficient entity practice

Question 8

Finding

Answer 8

generic term used to describe each discrete item of information observed or discovered during the survey about practices of an entity relative to the specific requirement being cited as being not met

Question 9

Fact

Answer 9

an event known to have actually happened. A truth knon by actual experience or oberservation.

Question 10

Forms CMS-2567/CMS-2567L Statement of Deficiencies and Plan of Correction

Answer 10

Official document on which citations are recorded

Question 11

Outcome

Answer 11

result/consequence of entinty practices (e.g., development of avoidable pressure sore/ulcer; reactiondue to receipt of wrong blood type.)

Question 12

Recipient

Answer 12

One who receives services (a patient, resident or a client) from an entity regardless of whether or not that person is eligible for, or is receiving, Medicare or Medicaid

Question 13

Requirement

Answer 13

any structure, process or outcome that is required by the law regulations, or the Life Safety Code(LSC)

Question 14

S/S

Answer 14

In the LTC survey, symbol accompanied by a unique letter (A through L) that illustrates the effect of the noncompliance on the nursing home resident (severity) and the number of residents actually or potentially affected (scope) by the providers noncompliance. The symbol with the letter assigned to the noncompliance appears under the tag number on the Form CMS-2567 for nursing homes

Question 15

Universe

Answer 15

the total number of individuals, records, observations, objects, related to the entity practice or recipients at risk as a result of a deficient practice. Used at the denominator when determining the extent of a deficient practice