CMS Nursing Home Compliance Glossary
Every acronym and term a Director of Nursing runs into — from CASPER to deemed status to the scope-and-severity grid — defined in one place, linked to the full guide where one exists.
Survey & Citations
CASPER
Certification And Survey Provider Enhanced Reports — the CMS reporting system state survey agencies and facilities use to pull a facility's own survey and complaint history.
ASPEN
Automated Survey Processing Environment — the software CMS surveyors use to document findings and generate the CMS-2567 during and after a survey.
Statement of Deficiencies
The formal name for Form CMS-2567 — the document listing every citation from a survey, each tied to an F-tag.
Full guide →Scope-and-Severity Grid
The A-through-L letter grid CMS surveyors use to rate how widespread and how serious a deficiency is — severity across the vertical axis, scope across the horizontal.
Full guide →Exit Conference
The meeting at the end of a survey where surveyors share preliminary findings with facility leadership, before the official Statement of Deficiencies is issued.
Look-Back Period
The window of past survey and complaint history CMS considers when scoring a facility — three years for the Health Inspection domain of the Five-Star Rating.
Full guide →Standard Survey
The routine, unannounced, comprehensive survey every certified nursing home undergoes roughly annually, covering the full range of CMS requirements.
Full guide →Complaint Survey
A targeted, unannounced survey triggered by a specific complaint rather than the routine annual cycle — narrower in scope than a standard survey.
Full guide →Enforcement & Penalties
Civil Money Penalty (CMP)
A federal fine CMS imposes on a noncompliant facility, assessed either per day of noncompliance or per instance of a specific deficiency.
Full guide →Denial of Payment for New Admissions (DPNA)
A mandatory remedy CMS imposes when a facility hasn't returned to substantial compliance within a set window — the facility stops receiving Medicare/Medicaid payment for any resident admitted after the DPNA takes effect.
Discretionary vs. Mandatory Remedy
CMS enforcement remedies split into mandatory ones (required once specific thresholds are met, like DPNA after 3 months) and discretionary ones CMS selects based on the facility's history and the deficiency's severity.
Termination
The most severe enforcement remedy — ending a facility's Medicare and/or Medicaid provider agreement entirely, ending its ability to bill either program.
Temporary Management
An enforcement remedy where CMS or the state installs a temporary manager with authority to make the facility changes needed to correct noncompliance.
Substantial Compliance
The status a facility returns to once all cited deficiencies are corrected and verified — the goal of every accepted Plan of Correction.
Quality & Ratings
Five-Star Quality Rating
CMS's public 1-5 star scoring system on Care Compare, combining the Health Inspection, Staffing, and Quality Measure domains into one overall rating.
Full guide →Health Inspection Domain
The Five-Star component scored from a facility's three most recent standard surveys plus complaint and infection-control surveys, weighted by how severe and widespread each citation was.
Full guide →Quality Measures (QM)
The Five-Star component built from clinical outcome data — things like falls, pressure ulcers, and antipsychotic medication use — reported through the MDS.
Deemed Status
A facility's certification obtained through an approved accrediting organization's survey instead of the standard state survey agency — treated as equivalent to a standard CMS certification.
Care Compare
CMS's public-facing website where families and researchers can look up a facility's Five-Star rating, inspection reports, and staffing data.
Compliance Programs
QAPI
Quality Assurance and Performance Improvement — the federally required, data-driven program under 42 CFR §483.75 every certified facility must maintain.
Full guide →QAA Committee
Quality Assessment and Assurance committee — the required minimum-membership group (DON, Medical Director, Infection Preventionist, plus others) that oversees a facility's QAPI program.
Full guide →Performance Improvement Project (PIP)
A structured, data-driven improvement project QAPI requires at least one of per year, targeting a high-risk or problem-prone area the facility's own data identified.
Full guide →Root Cause Analysis
A structured method for tracing a deficiency back to the systemic process failure behind it, rather than stopping at the individual incident — required for a PoC's systemic-change element to hold up.
Full guide →Infection Preventionist
The designated, trained staff member required under 42 CFR §483.80 to lead a facility's Infection Prevention and Control Program and participate in its QAPI process.
Full guide →Facility Designations
Special Focus Facility (SFF)
CMS's designation for nursing homes with a documented history of serious, persistent quality problems — subject to twice-yearly surveys and progressive enforcement.
Full guide →SFF Candidate
A facility that meets SFF selection criteria but hasn't yet been assigned one of CMS's roughly 88 active SFF slots — still worth treating as an early warning.
Full guide →Immediate Jeopardy (IJ)
A finding that a facility's noncompliance has caused, or is likely to cause, serious injury, harm, or death to a resident — the most severe citation category, with a 23-day removal clock.
Full guide →Actual Harm
A deficiency severity level below Immediate Jeopardy where a resident was demonstrably harmed, but the harm wasn't severe or widespread enough to meet the IJ threshold.
Substandard Quality of Care (SQC)
A deficiency finding in specific resident-care regulatory areas at actual-harm level or higher — triggers a mandatory onsite revisit within roughly 60 days.
Documentation & Reporting
Plan of Correction (POC)
The facility's formal, required response to a Statement of Deficiencies, due within 10 calendar days of receipt.
Full guide →CMS-2567
The Statement of Deficiencies and Plan of Correction form — the official document surveyors issue after a survey and facilities complete their response on.
Full guide →PBJ (Payroll-Based Journal)
The system facilities use to submit auditable, payroll-based staffing data to CMS quarterly, feeding directly into the Five-Star staffing rating.
Full guide →F-Tag
The federal regulation code CMS surveyors cite on a Statement of Deficiencies — each F-tag maps to a specific requirement in 42 CFR Part 483.
Full guide →MDS (Minimum Data Set)
The standardized clinical assessment every resident is periodically evaluated with — the data source behind Quality Measures and much of a facility's care planning documentation.
PoC360 turns every one of these terms into action
From a cited F-tag to a submitted Plan of Correction, PoC360 tracks the whole compliance vocabulary above as live data your team works from daily — not just definitions.
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