Free Microsoft Word - 50058 Regulatory Services Informal Dispute Resolution _IDR­ - Indiana

REGULATORY SERVICES INFORMAL DISPUTE RESOLUTION (IDR) RECORD
State Form 50058 (R3/3-04)

*The facility requesting IDR must complete the unshaded portions ONLY
Facility Name Address City, State Zip Licensee Name Facility Contact Person State Facility ID # Provider #: Date Survey Completed Date Facility Requesting IDR: Phone:

NOTE: Carefully read the complete instructions in the document entitled "Informal Dispute Resolution (IDR) Instructions". Please list each tag (including the severity and scope if applicable) that is disputed below. On a separate document other than the Plan of Correction (POC), provide a brief description summarizing the specific reasons for the dispute for each Tag. State explicitly what is disputed and why it is being disputed, citing specific errors on the CMS-2567, and where support for the dispute is located in supporting documents. Supporting documents should be labeled "Attachment A", "B", etc. Only documents that are pertinent and necessary to explain the facility's position will be considered. DO NOT submit excessive numbers of documents. SELECT EITHER A PAPER REVIEW OR FACE TO FACE.

CHECK ONE ONLY:
DISPUTED TAG/CODE NUMBER: ( INCLUDE SEVERITY & SCOPE)

ISDH PAPER REVIEW ISDH FACE TO FACE MPRO PAPER REVIEW FEE FOR SERVICE
THIS SECTION FOR OFFICE USE ONLY: RESOLUTION
____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted ____No Change ____Example(s) Deleted ____Tag/Code Changed ____Tag Deleted

FOR OFFICE USE ONLY: _____________________ IDR REQUESTED DATE _____________________ IDR SENT TO MPRO Date _______________ IDR COMPLETED DATE

INFORMAL DISPUTE RESOLUTION (IDR) INSTRUCTIONS

I.

Instructions For Requesting IDR:

Complete the unshaded portions of the IDR Tracking Record. Select one of the following: an ISDH paper review, an ISDH face-to-face review, or a MPRO paper review. The fact that a tag is being disputed must also be clearly stated on the Plan of Correction (POC). Include on a separate document from the POC, a one paragraph written summary of the reasons for the dispute for each tag, referencing supporting documents. Include the tag number and resolution proposed, i.e., remove tag, etc. If supporting documentation will accompany the IDR request, please only submit one copy at the same time you submit the POC; unless choosing MPRO review for substandard quality of care/immediate jeopardy, then two copies are required. Corrective actions must be specified on the POC, as if the tag were not being disputed. If selecting MPRO review, do not send the IDR request directly to MPRO. ISDH will forward all submitted documentation to MPRO. NOTE: A facility cannot choose more than one (1) option for federal deficiencies (for deficiencies affecting Medicare/Medicaid findings). MPRO is not an option for state findings only. A Service Agreement has been developed by MPRO. If selecting MPRO review, the facility administrator or designee must complete the appropriate portion of the Service Agreement and submit with the IDR request. MPRO will complete the IDR review and return a decision to ISDH within 20 days of receipt of review materials. MPRO will mail an invoice to the facility at the end of the month for services performed and payment is expected within 30 days. Ensure that the IDR request and POC are submitted within ten (10) calendar days of facility's receipt of the CMS-2567. A facsimile copy is acceptable. The IDR request must be submitted at the same time as the POC. The POC will be forwarded to the appropriate survey supervisor for review and approval, and the IDR request will be forwarded to the IDR survey supervisor. For cases involving deficient practices cited at immediate jeopardy or substandard quality of care, both MPRO and ISDH will select at least two qualified nurse reviewers to review the case. For all other cases, MPRO shall assign one qualified nurse reviewer. II. IDR Process

The IDR process will be conducted by a review of the materials submitted at the time of the request for IDR. All documents and materials that are to be considered for either face-to-face or paper review MUST be included at the time of the IDR request. The description of the dispute for each tag must be a clear and concise statement. State explicitly what is disputed and why it is being disputed, cite specific errors, and where support for the dispute is located in supporting documents. Pertinent portions of supporting documents should be outlined with a marker. Supporting documents should be labeled "Attachment A", "B", etc. A statement that the facts asserted on the CMS-2567 are not supported (or similar statement) is not sufficient. NOTE: Only documents that are pertinent and necessary to explain the facility's position will be considered. Excessive numbers of documents should NOT be submitted. ISDH will provide written notice to the facility of the outcome of the IDR process. If MPRO review is selected the facility with receive both the MPRO recommendation letter and the ISDH final determination letter. III. Further Information about IDR

Only deficiencies cited on the current survey, originally identified on the CMS-2567, may be disputed. Any evidence submitted to refute deficiencies must pertain only to the deficiencies and the language of the regulation cited. Only documents that are relevant to the dispute, and which were in existence at the time of the survey, will be considered. IDR does not contemplate bargaining between providers and the ISDH; rather it is a preliminary opportunity to refute survey findings that are believed to be inaccurate and to present evidence to support that belief. The purpose of this process is to give providers one opportunity to dispute cited deficiencies after a survey. The IDR process may not be used to delay the formal imposition of remedies or to challenge any other aspect of the survey process, including but not limited to: · · · · · Classification of deficiencies, i.e., scope and severity assessments; Remedies imposed by the enforcing agency; Failure of the survey team to comply with a requirement of the survey process; Inconsistency of the survey team in citing deficiencies among facilities; or Inadequacy of the IDR process.