CMS Enforcement Actions Explained: CMPs, DPNA, and Termination
A Civil Money Penalty is just one remedy on a much longer ladder. This guide unifies the full range of enforcement actions CMS can impose once a deficiency is confirmed — what each one does, how severity and scope decide which applies, and how remedies stack as noncompliance continues.
Quick answer
CMS enforcement remedies are a defined set of tools — including directed Plans of Correction, directed in-service training, State monitoring, Denial of Payment for New Admissions (DPNA), Civil Money Penalties (CMPs), temporary management, transfer of residents, facility closure, and termination — that CMS or the state survey agency can impose once a deficiency is confirmed. Which remedy applies depends on the deficiency's scope and severity, its relationship to other findings, the facility's compliance history, and how likely the remedy is to actually fix the problem.
What Are CMS Enforcement Remedies?
An enforcement remedy is distinct from the citation itself. A survey finding a deficiency and citing it under an F-tag is one step; CMS or the state separately deciding to impose a remedy — or not — is another. Enforcement remedies are governed procedurally under 42 CFR Part 488, Subpart F, with the operational detail spelled out in the CMS State Operations Manual, Chapter 7.
This article covers the full ladder at a level meant to orient a facility that's trying to understand where it stands. For the mechanics of appealing a CMP specifically, see how to stop or appeal a Civil Money Penalty, and for appealing the underlying survey finding itself, see how to appeal a CMS survey citation.
The Enforcement Ladder, Remedy by Remedy
| Remedy | What it does | When it typically applies |
|---|---|---|
| Directed Plan of Correction | CMS or the state prescribes the specific corrective steps instead of letting the facility write its own POC. | The facility’s own POC attempts have been inadequate, or the same deficiency keeps recurring. |
| Directed in-service training | Mandates staff training in a specific area directly tied to the cited deficiency. | A deficiency traces to a knowledge or skills gap rather than a resource or systemic failure. |
| State monitoring | State staff directly oversee the facility’s correction process, sometimes on-site. | CMS or the state needs more assurance than a written POC alone provides. |
| Denial of Payment for New Admissions (DPNA) | CMS and/or the state stop paying for newly admitted residents until substantial compliance is restored. | Compliance isn’t confirmed within the standard window, or as a mandatory remedy under specific triggers — see below. |
| Denial of payment for all residents | A broader version of DPNA that extends the payment denial beyond new admissions. | Noncompliance is severe or unresolved DPNA hasn’t produced correction. |
| Civil Money Penalty (CMP) | A federal fine assessed per day of noncompliance or per instance of a specific deficiency. | Immediate Jeopardy findings, repeat noncompliance, or a rejected/late Plan of Correction. See our full CMP guide. |
| Temporary manager | CMS or the state appoints an outside manager with real authority to make operational changes. | Often paired with Immediate Jeopardy findings where facility leadership hasn’t removed the danger fast enough. |
| Transfer of residents / facility closure | Residents are relocated and the facility is closed, generally alongside or ahead of termination. | The most severe, last-resort situations where resident safety can’t otherwise be assured. |
| Termination | The provider agreement itself ends — the facility loses Medicare and/or Medicaid certification entirely. | Substantial compliance isn’t reached within the enforcement cycle, or immediately for unabated Immediate Jeopardy. |
These aren't mutually exclusive — a single survey can trigger several remedies at once (for example, a CMP alongside DPNA), and remedies can stack as noncompliance continues across revisits.
How CMS Decides Which Remedy to Use
CMS and the state survey agency weigh several factors when choosing among remedies: the scope and severity of the deficiency, the relationship of that deficiency to other findings from the same survey, the facility's prior history of noncompliance, and how likely a given remedy is to actually achieve and sustain correction — not a single fixed formula that produces the same answer every time.
A related distinction matters: some remedies require CMS to give the facility an opportunity to correct before the remedy takes effect. Others — including Civil Money Penalties, temporary management, directed Plans of Correction, directed in-service training, DPNA, and State monitoring — can be imposed without that opportunity, particularly where the deficiency is serious. This is part of why an Immediate Jeopardy finding moves so much faster than a routine deficiency — the enforcement framework is built to act immediately when the risk is serious enough.
When a Remedy Becomes Mandatory
Most remedies are discretionary, but a few become mandatory once specific conditions are met. A mandatory DPNA must be imposed when a facility is not in substantial compliance three months after the last day of the survey that identified the deficiency, and also when a facility has furnished substandard quality of care on its last three consecutive standard surveys. On the most severe end, an unabated Immediate Jeopardy finding puts the facility on a hard path toward termination — CMS and the state must terminate the provider agreement within 23 calendar days of the survey exit date unless the jeopardy is removed first.
This is also why correction speed matters more than most facilities initially assume: a discretionary remedy today can become a mandatory one a few months from now purely because of elapsed time, independent of whether the underlying care problem has actually improved.
How Remedies Combine in Practice
Remedies rarely arrive one at a time in a clean sequence — in practice they stack and overlap. A facility cited for a serious, isolated deficiency might see only a directed Plan of Correction paired with directed in-service training on the specific gap. A facility with a pattern of repeat findings across several surveys is far more likely to see a Civil Money Penalty layered on top of DPNA, with State monitoring added if the state isn't confident the facility can self-correct. And a facility with an unabated Immediate Jeopardy finding can see a temporary manager, a CMP at the upper end of the penalty range, and the 23-day termination clock all running at the same time.
The through-line across all of these scenarios is the same: the remedies get more numerous and more severe as either the underlying finding gets worse or the facility's compliance history gets longer. A facility with a clean history facing its first serious citation is in a materially different position than a facility facing the same citation for the second or third time — even though the F-tag on the 2567 might look identical.
Where This Fits the Post-Survey Timeline
Enforcement decisions don't happen in isolation from the rest of the post-survey process — they run alongside the Plan of Correction deadline, state review, and revisit cycle. See our complete breakdown of what happens after a CMS survey for exactly how the POC deadline, revisit timing, and enforcement decisions interact stage by stage.
How This Connects to Special Focus Facility Status
A pattern of repeated, serious deficiencies — the kind that drives escalating enforcement remedies — is also a primary driver of Special Focus Facility (SFF) designation. Facilities under active enforcement should treat SFF risk as a related, not separate, concern: the same compliance history that triggers a directed Plan of Correction or a CMP today is often the same history CMS's SFF scoring system weighs.
Common Mistakes
- Assuming a Civil Money Penalty is the only enforcement remedy CMS has — it’s one of several, and often not the first one used
- Assuming filing an appeal pauses a remedy from taking effect or continuing to accrue — it generally doesn’t
- Treating DPNA as a minor administrative inconvenience rather than the direct cash-flow hit it actually is once new-admission revenue stops
- Not tracking enforcement and remedy history across surveys — CMS enforcement policy calls for remedies of increasing severity on repeat noncompliance, so history compounds
- Waiting for a formal enforcement notice before starting corrective action, instead of treating the Plan of Correction window itself as the fastest way to avoid escalation
Tools That Help
See your enforcement exposure by state
PoC360's free State Enforcement Report pulls live CMS data on fines and top-cited F-tags by state, and CMP Shield timestamps every corrective action from the moment a survey is imported — building the evidence trail that matters most once any remedy is on the table.
Summary Checklist
Frequently Asked Questions
What are CMS enforcement remedies?+
A defined set of tools CMS and state survey agencies can impose after a deficiency is confirmed, separate from the citation itself — including directed Plans of Correction, directed in-service training, State monitoring, Denial of Payment for New Admissions, Civil Money Penalties, temporary management, transfer of residents, facility closure, and termination of the provider agreement.
What's the difference between DPNA and termination?+
DPNA (Denial of Payment for New Admissions) stops Medicare/Medicaid payment for newly admitted residents while the facility works toward substantial compliance — the facility keeps operating and keeps its existing residents. Termination ends the provider agreement entirely; the facility loses its certification to participate in Medicare and/or Medicaid altogether.
Can CMS skip straight to termination without trying other remedies first?+
In the most severe cases — most notably an Immediate Jeopardy finding that isn't abated — CMS and the state must move toward termination on a hard, short timeline without necessarily working through every lower remedy first. For lower-severity noncompliance, enforcement generally escalates through less severe remedies before reaching that point.
Does CMS have to give a facility a chance to correct before imposing a remedy?+
Not always. Several remedies — including Civil Money Penalties, temporary management, directed Plans of Correction, directed in-service training, DPNA, and State monitoring — can be imposed without giving the facility an opportunity to correct first, particularly for serious findings. Lower-severity deficiencies more often follow the standard correct-then-verify cycle.
How does CMS decide which remedy to use?+
CMS and the state weigh the scope and severity of the deficiency, how the deficiency relates to other findings, the facility's history of noncompliance, and the likelihood that a given remedy will actually achieve and sustain correction — not a single fixed formula.
When does DPNA become mandatory rather than discretionary?+
DPNA must be imposed when a facility is not in substantial compliance three months after the last day of the survey that identified the deficiency, and also when a facility has been found to have furnished substandard quality of care on its last three consecutive standard surveys.
Does an enforcement remedy affect a facility's Five-Star Rating?+
Indirectly, yes — the underlying deficiencies that trigger enforcement remedies also feed the Health Inspection domain of the Five-Star Rating, and an active Special Focus Facility designation, which often follows a pattern of escalating enforcement, caps the Overall Rating at 3 stars regardless of other performance.
Can more than one enforcement remedy apply to the same survey?+
Yes. A single survey can generate multiple deficiencies, and each one can carry its own remedy — it's common for a serious survey to produce a Civil Money Penalty on one citation alongside a directed Plan of Correction or DPNA tied to the facility's broader compliance pattern, all running on overlapping timelines.
Sources: 42 CFR Part 488, Subpart F, CMS State Operations Manual Chapter 7, 42 CFR §488.410, CMS Nursing Home Enforcement guidance. Last reviewed 2026-09-30. We review this article as CMS regulations and enforcement guidance change.