You may, of course, take steps to come into compliance with the Medicare Conditions of Participation. If you believe
compliance has been achieved, please notify this office immediately. If you believe your hospital will be able to come into
compliance, you should submit an allegation of compliance and plan of correction that addresses all the deiciencies cited at
the survey of December 1, 2012. If we accept your allegation of compliance, the ODH will conduct a revisit. If you cannot
achieve compliance by the termination date, you may reapply to establish your facility's eligibility to participate as a provider
of services under Title XVIII of the Social Security Act.
If you believe your hospital will be able to come into compliance, you should submit a plan of correction that meets the
following criteria: (1) It clearly states the specific nature of the corrective actions for each deficiency. (2) It sets reasonable
completion dates for all deficiencies prior to the termination date unless an extension is requested and approved.
describes how your plan/action will prevent recurrence. And (4), it describes who will be the person(s) responsible for
implementing and monitoring the plan for future compliance with the regulations. A response to each deficiency on the CMS-
2567 is required and the right side of the CMS-2567 must be used to document your plan for corrective action. The plan of
correction must be signed and dated on the bottom of the first page of the CMS-2567 by the authorized official at your
hospital. Additional documentation may be attached to the CMS-2567, when necessary. If a deiciency has been corrected
since the survey, this should be indicated on the form along with the date of correction.
Your plan of correction should be submitted within ten (10) calendar days of the date of receipt of this letter by your ofice.
Copies of your plan of correction should be sent to both CMS and ODH. The address for CMS is: CMS, Non-Long Term
Care Certification & Enforcement Branch, Attention: Tamra Swistowicz, 233 North Michigan Avenue, Suite 600, Chicago,
60601 and to ODH: (Ohio Department of Health, Division of Quality Assurance, Bureau of Community Health Care
Facilities and Services, 246 North High Street, Columbus, Ohio 43215, Attention: Roy Croy.
If you believe that the decision to terminate your participation in the Medicare program is not correct, you may request a
hearing before an Administrative Law Judge of the Department of Health and Human Services, Departmental Appeals Board.
If you desire a hearing, you must request it no later than sixty (60) days from the date you receive this notice. The request for
a hearing should state why the decision is considered incorrect and should be accompanied by any evidence that you decide
to bring to the attention of the hearing examiner. Evidence may also be presented at the hearing, where you may be
represented by counsel. The request for a hearing should be sent to Kim Robinson, Director, Department of Health and
Human Services, Departmental Appeals Board, MS 6132, Civil Remedies Division, 330 Independence Avenue, SE, Cohen
Building, Room G-644, Washington, DC 20201.
If you have any questions regarding this matter, please contact Tamra Swistowicz, in the Chicago Regional Office at (312)
Certiication & Enforcement Branch
Ohio Department of Health (0H00066649, OH00064445, OH00064169)
Ohio Department of Jobs and Family Services
The Joint Commission