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Division of Licensing Services

Office of Long Term Care Licensing Definitions

Federal recertification surveys:

Under a contract between the State Agency (AZDHS) and the Centers for Medicare and Medicaid Services (CMS), the Office of Long Term Care Licensing conducts certification and recertification surveys in all skilled nursing and nursing facilities participating in the Medicare and Medicaid programs. These surveys are routinely conducted every 9 to 15 months.

Each deficiency in the federal survey contains an alphabetical ranking to identify the seriousness of that deficient practice. The rankings are based on the following table:

Federal Scope and Severity Grid

Isolated Pattern Widespread
Immediate Jeopardy J K L
Actual Harm G H I
Potential for more than Minimal Harm D E F
Minimal Harm A B C
Yellow
substandard quality of care when deficiencies fall under the categories of Quality of life, Quality of care and Facility practices as defined in the Federal Regulations.
Green
substantial compliance with Federal Regulations

State relicensure surveys:

The Office of Long Term Care Licensing conducts licensure and relicensure surveys annually. Based on the relicensure survey, the facility is issued a Quality Rating with an alphabetical ranking of A, B, C, or D with A being excellent.

Complaint Investigations:

Complaint investigations are conducted for a complaint recieved from the public, residents, families, other agencies, or other interested parties. Timing of complaint investigations is based on the severity of the issues of concern, and the timing within the survey cycle.

Informal dispute resolutions and appeals:

1.

Informal dispute resolutions: a provider may request in writing to dispute one or more findings in a Statement of Deficiencies for either federal or state surveys, or complaint investigations.  Possible resolutions to this request may be: upholding the finding(s), modifying the finding(s), removing the finding(s) and/or changing the scope and severity.

2.

Appeals: A provider may appeal an adverse decision by the Department resulting from a Statement of Deficiencies to a hearing before an Administrative Judge. The Administrative Judge may recommend to the Director of the Department of Health Services that the Department’s decision be upheld, modified, or disapproved.  A provider may also exercise a right to appeal federal deficiencies through the federal appeals process.

Plans of Corrections (POCs):

The provider's plan of correction is created and submitted to the Office of Long Term Licensing within 10 days of receiving a Statement of Deficiencies from a survey.  The plan of correction must include how the provider has corrected the deficient practice for the residents cited, how they will identify other potential residents who may be affected by the same deficient practice, what systems will be implemented, how the facility will monitor that the plan is working and compliance is not only attained but sustained over time, and when the deficient practice will be corrected.

Public Files:

The Office of Long Term Care Licensing in Phoenix maintains files available for public review that include copies of applications and supporting documents, licenses, inspection and complaint investigation reports, Statements of Deficiencies, Plans of Correction, and other public non-confidential information. These files may be reviewed during normal business hours at the office.

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2007-2023 Arizona Department of Health Services. All rights reserved. Last Modified: 08/01/2023