DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services
Consortium for Quality Improvement and Survey and Certification Operations
Western Consortium - Division of Survey and Certification
Refer to: WCDSC-RO IX-

[Receipt Of This Notice Is Presumed To Be July 19, 2017- Date Notice Faxed]
Important Notice - Please Read Carefully
July 19, 2017
CMS Certification Number: 55-5221
Bill Bostic, Administrator
Surprise Valley Community Hospital D/P SNF
741 N. Main Street
Cedarville, CA 96104
Dear Administrator:
On June 29, 2017, the California Department of Public Health (State Survey Agency) completed a
recertification survey of your facility, Surprise Valley Community Hospital D/P SNF, in which it was
determined that your facility was not in substantial compliance with Federal requirements for nursing homes
participating in the Medicare and/or Medicaid programs. See 42 C.F.R. Part 483. The deficiencies documented
during that survey were listed on Form CMS-2567 (a copy of which you were previously provided).
As a result of the June 29, 2017 survey findings, which were listed on a Statement of Deficiencies (Form
CMS-2567) that was forwarded to you after the survey, the State Survey Agency notified you that it would
recommend to the Centers for Medicare & Medicaid Services (CMS) that certain remedies be imposed.
CMS’s Approval of Certification/Finding of Noncompliance
Having reviewed the June 29, 2017 survey findings and the State Survey Agency’s recommendations, this office
has concluded that we concur with the survey findings documented during the survey (and listed on the
above-referenced Form CMS-2567 for that survey).
Accordingly, this office has approved a certification/finding of noncompliance based on our conclusion that
Surprise Valley Community Hospital D/P SNF was not in substantial compliance with nursing home
participation requirements at 42 C.F.R. Part 483 as documented by the survey completed on June 29, 2017 (and
set forth in the referenced Form CMS-2567, the contents of which are incorporated herein by reference).

CMS’s Imposition of Remedies
Denver Regional Office
1600 Broadway, Suite 700
Denver, CO 80202

San Francisco Regional Office
90 7th Street, Suite 5-300 (5W)
San Francisco, CA 94103

Seattle Regional Office
2201 Sixth Avenue, MS-46
Seattle, WA 98121

 . Wanda Grove,
Surprise Valley Community Hospital D/p Snf

Page 2

Based upon this certification/finding of noncompliance, we have determined, in accordance with sections
1819(h) and 1919(h) of the Social Security Act and the enforcement regulations at 42 C.F.R. Part 488 to impose
the following remedies:
[X] Per Instance Civil Money Penalty [42 C.F.R. § 488.430] in the amount of $15,205.00 for the
noncompliance identified under F-tag 309 in the Statement of Deficiencies (Form CMS-2567) for the June 29,
2017 survey. 1
[X] Denial of payment for new admissions [42 C.F.R. § 488.417(a)], effective August 3, 2017.
The denial of payment for new admissions will continue in effect until CMS either determines that your facility
is in substantial compliance with the applicable participation requirements or terminates your facility’s
Medicare provider agreement. See 42 C.F.R. 488.454.
In this regard (as discussed more fully below), CMS will terminate your facility’s Medicare provider agreement
if substantial compliance with Medicare participation requirements is not promptly achieved and maintained. If
such substantial compliance is not achieved and maintained, you will be informed by future notice of the exact
date of termination. You are reminded that Congress has mandated that under no circumstances will
termination of a facility be effective later than six months from the last day of the survey documenting the
facility's failure to be in substantial compliance. See 42 C.F.R. § 488.412(d). In this case, since the first survey
documenting your facility’s failure to be in substantial compliance was completed on June 29, 2017, under no
circumstances will the termination be effective later than December 29, 2017. It is emphasized, however, that
the termination date may be implemented sooner (after proper notice).
More particularly, you have been informed by the State Survey Agency that you must promptly submit an
allegation of compliance and an acceptable plan of correction addressing each of the cited deficiencies on the
Form CMS-2567 for the survey completed on June 29, 2017. If this is timely submitted, and it is determined
that the information provided credibly establishes that you have taken action to correct all of the identified
deficiencies, CMS may choose to exercise its discretion and authorize a revisit of your facility to determine
whether the facility has achieved substantial compliance with controlling participation requirements at 42
C.F.R. Part 483. If acceptable documentation of corrective action is not timely submitted (as described above),
or if timely submitted but a revisit survey documents a continued failure to be in substantial compliance, this
office will expeditiously proceed to terminate your Medicare provider agreement. If this should occur, you will
receive a further detailed notice identifying the date of termination and your respective appeal rights.
We have coordinated this action with the State Medicaid Agency, which will take concurrent action under Title
XIX of the Social Security Act.
Denial of Approval of Nurse Aide Training
Please note that, under certain specified circumstances, sections 1819(f)(2)(B) and 1919(f)(2)(B) of the
Social Security Act, 42 U.S.C. §§ 1395i-3(f)(2)(B) and 1396r(f)(2)(B), require withdrawal of approval of
nurse aide training and competency evaluation programs and nurse aide competency evaluation
programs offered by or in a facility. See 42 C.F.R. § 483.151(f)(1). As a result of the imposition (as
noticed herein) of the denial of payment for new admissions and civil money penalty, this provision is
applicable to your facility. You will receive further details about the denial of approval of nurse aide

 . Wanda Grove,
Surprise Valley Community Hospital D/p Snf

Page 3

training from the State. In light of the foregoing, you may finish any nurse assistant training class you
are presently conducting; you may not, however, start another such class.
Additional Documentation Supporting Certification/Finding of Noncompliance
It is emphasized that even though the certification/finding of noncompliance (and thus enforcement action)
noticed in this letter is based on the findings of the survey as set forth in the Form CMS 2567 referenced herein,
CMS may have additional evidence and information (including, but not limited to State licensure information,
correspondence, provider records, or verified complaints) relating to the deficiencies identified during the
survey that may be presented at the time of (or before) an administrative hearing challenging CMS's
certification/finding of noncompliance based on the June 29, 2017 survey. This corroborating
evidence/information may be used at a hearing to resolve possible conflicts of factual information and to
otherwise support CMS's adverse findings. Accordingly, nothing in this notice should be viewed as limiting or
constraining CMS's right to present this additional evidence/information at an administrative hearing. (See
State Operations Manual Section 3026F.)
Appeal Rights
If you disagree with our certification/finding of noncompliance that is based upon our determination that
Surprise Valley Community Hospital D/P SNF was not in substantial compliance with controlling Medicare
participation requirements at 42 C.F.R. Part 483 as documented during the survey completed on June 29, 2017,
you or your legal representative may request a hearing before an administrative law judge of the Department of
Health and Human Services’ Departmental Appeals Board since this certification/finding of noncompliance has
led to the actual imposition of an enforcement remedy specified at 42 C.F.R. § 488.406. You may appeal the
certification/finding of noncompliance which led to an enforcement action, but you cannot appeal the
enforcement remedy itself. See 42 C.F.R. § 488.408(g). Procedures governing this process are set out in 42
C.F.R. Part 498, Subpart D. A request for a hearing should be filed electronically no later than sixty (60)
calendar days from the date of receipt of this notice. (We remind you that, as indicated above, since this notice
is being sent to you by facsimile, your appeal must be filed no later than sixty (60) days from the date indicated
on this notice.) See 42 C.F.R. 498.40(a)(2).
You can file your appeal electronically at the Departmental Appeals Board Electronic Filing System Web
site (DAB E-File) at https://dab.efile.hhs.gov. To file a new appeal using DAB E-File, you first need to
register a new account by: (1) clicking Register on the DAB E-File home page; (2) entering the information
requested on the "Register New Account" form; and (3) clicking Register Account at the bottom of the form. If
you have more than one representative, each representative must register separately to use DAB E-File on your
behalf.
The e-mail address and password provided during registration must be entered on the login screen at
https://dab.efile.hhs.gov/user_sessions/new to access DAB E-File. A registered user's access to DAB E-File is
restricted to the appeals for which he or she is a party or authorized representative. Once registered, you may file
your appeal by:
-Clicking the File New Appeal link on the Manage Existing Appeals screen, then clicking Civil Remedies
Division on the File New Appeal screen.
And,

 . Wanda Grove,
Surprise Valley Community Hospital D/p Snf

Page 4

-Entering and uploading the requested information and documents on the "File New Appeal-Civil Remedies
Division" form.
At minimum, the Civil Remedies Division (CRD) requires a party to file a signed request for hearing and the
underlying notice letter from CMS that sets forth the action taken and the party's appeal rights. All documents
must be submitted in Portable Document Format ("PDF"). Any document, including a request for hearing, will
be deemed to have been filed on a given day, if it is uploaded to DAB E-File on
or before 11:59 p.m. ET of that day. A party that files a request for hearing via DAB E-File will be deemed to
have consented to accept electronic service of appeal-related documents that CMS files, or CRD issues on
behalf of the Administrative Law Judge, via DAB E-File. Correspondingly, CMS will also be deemed to have
consented to electronic service. More detailed instructions on DAB E-File for CRD cases can be found by
clicking the CRD E-File Procedures link on the File New Appeal Screen for CRD appeals.
If you do not have the ability to file your appeal electronically, you may file it in writing, but must
provide an explanation as to why you cannot file submissions electronically and request a waiver from
e-filing in the mailed copy of your request for a hearing. Written request for appeals must also be filed
no later than sixty (60) calendar days from the date you receive this notice, and must be submitted to the
following address:
Department of Health and Human Services
Departmental Appeals Board, MS 6132
Civil Remedies Division
330 Independence Ave, SW
Cohen Building, Room G-644
Washington, D.C. 20201
If you choose to file your appeal to the Departmental Appeals Board, please also send a hard copy of the
hearing request (excluding exhibits and attachments) to:
Steven D. Chickering
Associate Regional Administrator
Western Division of Survey and Certification
Centers for Medicare & Medicaid Services
90 7th Street, Suite 5-300 (5W)
San Francisco, California 94103-6707
It is emphasized that a request for a hearing must identify the specific issues, and the findings of fact and
conclusions of law with which you disagree. It must also specify the basis for contending that the findings and
conclusions are incorrect. See 42 C.F.R. § 498.40(b). If a hearing request does not fully comport with the
timing and specificity requirements of 42 C.F.R. § 498.40, CMS will promptly move, as appropriate, for
summary judgment on certain issues and/or dismissal of your entire filing.
If your hearing request is not dismissed you will have an opportunity to present evidence and further
argument at an in-person hearing or on the record, where you may be represented by counsel at your
own expense.

 . Wanda Grove,
Surprise Valley Community Hospital D/p Snf

Page 5

Details Regarding the Civil Money Penalty
In lieu of requesting a hearing to challenge the certification/finding of noncompliance noticed herein (that is, the
certification/finding of noncompliance based on the determination that Surprise Valley Community Hospital
D/P SNF was not in substantial compliance with controlling Medicare participation requirements at 42 C.F.R.
Part 483 as documented during the survey completed on June 29, 2017), you may choose to waive your right to
such a hearing. A decision to exercise this waiver option must be made in writing within sixty (60)
calendar days from the date of this notice (which is being sent to you via facsimile). See 42 C.F.R.
488.436. Please note that you must send your waiver to the San Francisco Regional Office address
indicated at the top of page 1 of this notice.
Such a waiver of your hearing rights would constitute an acceptance of this office's determination that your
facility was not in substantial compliance as documented during the survey completed on June 29, 2017; and an
acceptance of all enforcement remedies under 42 C.F.R. § 488.406 resulting from the certification/finding of
noncompliance not being challenged (i.e., the certification/finding of noncompliance based on the June 29, 2017
survey). By your waiver, therefore, you would accept all of the enforcement remedies that are being imposed by
this office as a result of our determination that your facility was not in substantial compliance with 42 C.F.R.
Part 483 participation requirements as documented during the survey completed on June 29, 2017. The total
amount of the affected civil money penalty of $15,205.00, however, would be reduced by thirty-five percent
(35%) to $9,883.25 in accordance with 42 C.F.R. § 488.436(b).
Independent Informal Dispute Resolution (Independent IDR)
Because a civil money penalty was imposed for the June 29, 2017 survey, the civil money penalty will be
subject to the combined civil money penalty collection and escrow provisions and Independent IDR process set
forth in 42 C.F.R. § 488.431. We are authorized pursuant to 42 C.F.R. § 488.431(b) to collect your CMP and
place it in an escrow account on the earlier of the following dates: 1) the date on which the Independent IDR
process is complete or 2) 90 days from the date of this notice. During the Independent IDR process a facility
may dispute the factual basis of the cited deficiencies for which it requested Independent IDR. You may also
contest scope and severity assessments for deficiencies which resulted in a finding of substandard quality of care
(SQC) or immediate jeopardy.
You are required to send your written request for an Independent IDR, along with the specific deficiencies being
disputed, and an explanation of why you are disputing those deficiencies (or why you are disputing the scope
and severity assessments of deficiencies which been found to constitute SQC or immediate jeopardy) to:
Joanne Gilchrist
District Manager for the Chico District Office
California Department of Public Health
126 Mission Ranch Boulevard
Chico, CA 95926
Telephone: (530) 895-6711
Please include a copy of this CMS notice with your written request for an Independent IDR.
This request must be sent within 10 calendar days of receipt of this CMS notice. A request for an
Independent IDR process will not delay the effective date of any enforcement remedy imposed on your facility,
and it will not delay our collection of your facility’s CMP for more than ninety (90) days.

 . Wanda Grove,
Surprise Valley Community Hospital D/p Snf

Page 6

Please note further that an incomplete IDR or Independent IDR process will not delay any deadline listed above
under “Appeal Rights” for requesting a hearing or under “Details Regarding the Civil Money Penalty for
requesting waiver of hearing rights.
Filing of Medicare or Medicaid Claims
Any filing of Medicare or Medicaid claims for new admissions during the period that a denial of payment for
new admissions (DPNA) is in effect could result in such claims being considered “false” claims under
applicable Federal statutes, thereby potentially subjecting the filing entity to a referral to the appropriate
authorities and possibly to the penalties prescribed under such statutes. An exception possibly applies where a
timely appeal of the controlling certification/finding of noncompliance is filed (and remains pending) under 42
C.F.R. Part 498, and where your facility has made arrangements acceptable to your Medicare and Medicaid
fiscal intermediaries to submit the claim (or claims) with prominent flagging clearly indicating that the claim(s)
is/are being filed not for current payment, but “under protest” and for the sole purpose of preserving a timely
filing should the facility prevail on its administrative appeal under 42 C.F.R. Part 498.
If you have any questions regarding this action, you may contact Yvonne Pon of my staff at (415) 744-3710.

Sincerely,

Steven D. Chickering
Associate Regional Administrator
Western Division of Survey and Certification

cc:

State Survey Agency
State Medicaid Agency