Life Safety Code Independent Informal Dispute Resolution (IIDR) Procedures

Purpose: To offer nursing home providers the opportunity to dispute cited deficiencies with an entity independent of the State Survey Agency when a civil money penalty (CMP) is imposed for that deficiency which is at scope and severity (s/s) level of G (harm) or above.

Procedure:

  1. Availability of IIDR: If the provider believes that a specific deficiency or any finding within a deficiency cited during a survey is factually inaccurate and the provider would like the opportunity to dispute the specific deficiency and/or finding(s), and if that deficiency is associated with a civil money penalty, the provider will be given one opportunity to do so. IIDR requests must be submitted in writing within 10 calendar days of receipt of the initial Notice of Imposition of a CMP letter to a facility from Centers for Medicare & Medicaid Services (CMS). If the provider exceeds this time frame, the IIDR coordinator will deny the request for IIDR.

    The request must be submitted through overnight mail delivery to the Division of Health Service Regulation, as follows:

    Construction Section: Steven Lewis, Section Chief
    1800 Umstead Drive, Raleigh, NC 27603

    The provider may request IIDR for any deficiency cited at s/s level of G and above that is associated with a civil money penalty. The provider may dispute s/s levels for any deficiency cited at s/s of G and above that is associated with a civil money penalty. Scope and severity may be changed.

  2. IIDR format. The IIDR will be conducted by a single reviewer. The reviewer will be a qualified former life safety code surveyor who is not currently working for a nursing home or the State Survey Agency.

  3. Submission of written material. The facility must submit relevant written information for review to the Construction Section Chief no later than 10 calendar days of receipt of the initial Notice of Imposition of a CMP letter to a facility from CMS. The facility must submit two copies of material and highlight or use some other means to identify written information pertinent to the disputed deficiency(ies). The IIDR reviewer will not review additional written material that does not meet these requirements. The reviewer has no obligation to review any documents that are not legible. The facility must also provide the name of the involved resident(s), and the name and contact information of the resident representative no later than 10 calendar days of receipt of the initial Notice of Imposition of a CMP letter to a facility from CMS. The provider will be informed of the IIDR process the day of receipt of the written request and information. The Construction Section Chief or designee will notify the involved resident, the resident representative and the ombudsman of the opportunity to provide written statements pertinent to the deficiency(ies). This notification will be within two working days after the Construction Section receives the written request and information from the facility. These individuals will be given five calendar days from the date the Construction Section receives the written IIDR request and written information, to submit information to the Construction Section Chief or designee.

  4. Scheduling IIDRs. Within two working days of receipt of a written request for IIDR, the Construction Section Chief or designee will verify that the IIDR has been requested in accordance with the provisions of federal regulation. Also within two working days of receipt of the written request, the Construction Section will notify the IIDR reviewer of his responsibility to complete the review and the time frame requirements. The date of completion will be 30 calendar days from the date of the initial Notice of Imposition of a CMP letter to a facility from CMS. The Construction Section will send by overnight mail the facility submitted information to the IIDR reviewer. This mail will be sent within two working days of receipt of the facility submitted written information. The entire statement of deficiencies will also be included in the mailing. The mailing envelope will be marked with a confidentiality stamp. On the fifth calendar day from receipt of the written request, the Construction Section will send by overnight mail any written statements from the ombudsman, involved resident, and/or resident representative to the IIDR reviewer with notice of confidentiality on the mailing envelope.

  5. Notification of IIDR. The Construction Section Chief ensures that the Construction Section and State Long-Term Care Ombudsman are notified of the facilities requesting IIDR. The Construction Section will also notify the CMS enforcement representative and manager. Entries will be made into the federal computer system. All notifications will be made within two working days of receipt of the written request from the facility.

  6. IIDR panel activity. Only those deficiencies identified in the facility’s request will be reviewed in IIDR. There will be no contact made to the survey team or the provider. The IIDR reviewer will not seek input from others in the decision making process. The IIDR reviewer may consult with the Construction Section Chief only with a process or policy question.

  7. Decision. The IIDR reviewer may decide that a deficiency or finding is to be upheld or deleted, or that a deficiency is to be upheld with deletion of a finding(s), or that scope and severity of the deficiency(ies) may be lowered or increased, or that additional tags need to be added to the statement of deficiency, or that the deficiency in question needs to be moved to a different federal tag. The decision will be submitted in writing electronically to the Construction Section Chief or designee within 10 working days after the decision or no later than day 30. The written decision will include the result for each deficiency challenged and a brief summary of the rationale for that result. The written decision will reference specific documents submitted by the facility that demonstrate a deficiency should not have been cited, or that demonstrates a change in s/s. The written decision statement will explain the reviewer’s rationale to support additional tags or a change in the federal tag. The written decision will also reference the statements provided by the involved resident, resident representative and/or ombudsman if those documents influenced the decision. If the Construction Section agrees with the decision, the Section Chief will ensure that the facility, the Section and CMS are notified in writing of the decision no later than the next business day. If the Section Chief does not agree with the decision, the complete record will be forwarded to CMS for the final decision. The complete packet will consist of the facility submitted information, any written statements from the involved resident, the resident representative and/or the ombudsman, the written statement from the IIDR reviewer, and a written document from the Construction Section Chief clearly explaining the reason for disagreement. The packet will be sent by overnight mail within five working days after the Construction Section receives the decision from the IIDR reviewer. Final decisions are made within 60 days of receipt of the facility request. After receiving a final decision from CMS, the Construction Section will ensure that the process is completed. Completed means that a final decision from the IIDR process has been made, a written report generated, the Construction Section has provided written notice of this decision to the facility, and the federal computer system has been updated to reflect the final decision. The completion process will occur within two working days after the Construction Section receives a final decision. Final decisions are also shared with the Section, and the State LTC Ombudsman.

  8. Actions generated by IIDR. When a final decision changes the statement of deficiency, the Construction Section staff will:

    1. send the facility an amended statement of deficiencies form (CMS-2567) with instructions to input the original plan of correction and return to the Section within a 10-day period;
    2. recommend rescinding any enforcement action as applicable;
    3. ensure the Division website is updated with the final statement of deficiencies.

  9. Invalid use of IIDR. The facility cannot use the IIDR process to challenge the following:

    1. Remedy (ies) imposed by the enforcing agency;
    2. Any revisit survey conducted on or before January 1, 2012 for which an enforcement action was initiated before January 1, 2012, even if the civil money penalty is imposed after January 1, 2012;
    3. Questions or issues from a previous survey;
    4. Any deficiency cited at s/s less than G (i.e. D, E, and F) even when a civil money penalty is imposed (i.e. from a revisit);
    5. Survey findings that have already been the subject of an informal dispute resolution (IDR) unless the IDR was completed prior to the imposition of the civil money penalty;
    6. Failure of the survey team to comply with a requirement of the survey process;
    7. Inconsistency of the survey team in citing deficiencies among facilities;
    8. Inadequacy or inaccuracy of the IIDR process; or
    9. Surveyor behavior.

Reference: S&C 12-08-NH (PDF, 170 KB)