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05/07/2026

Survey Tip of the Week: Acceptable Credible Evidence

In the April 2026 update to the Centers for Medicare & Medicaid Services memo QSO-26-03-NH, CMS clarified what constitutes acceptable credible evidence when determining compliance. An offsite desk paper review revisit may be conducted for less serious (D, E, and F scope and severity levels without substandard quality of care) when on-site observations are not necessary to evaluate corrective actions. In these cases, compliance is determined based on evidence submitted by the facility demonstrating that the plan of correction (POC) was fully implemented and that all deficiencies were corrected. Supporting documentation must be sufficient to validate the corrective actions and ensure the integrity of the verification process. See page 220 of the memo for a list of acceptable credible evidence. 

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