[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-263505-105":53,"doc-detail-263505-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","cms-1539-medicaremedicaid-recertification-transmittal-id-y54l","CMS-1539 Medicare/Medicaid Recertification Transmittal ID Y54L","","CMS-1539 Medicare/Medicaid certification and transmittal package for facility participation in the Medicare and Medicaid programs. It records key provider identifiers, facility name and address, action type, effective and survey dates, accreditation and certification status, certification period details, bed counts, and state survey remarks. It also includes a formal Minnesota Department of Health recommendation letter to CMS supporting recertification based on substantial compliance with participation requirements under 42 CFR Part 483.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/cms-1539-medicaremedicaid-recertification-transmittal-id-y54l/263505/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/cms-1539-medicaremedicaid-recertification-transmittal-id-y54l/263505.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Vance","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-14",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the CMS-1539 Medicare/Medicaid certification transmittal cover?","Question",{"text":108,"@type":109},"It compiles facility identifiers, certification-related actions, survey and effective dates, bed counts, and state survey information, then supports a CMS participation determination. The included letter recommends recertification based on substantial compliance.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which facility is listed in the document?",{"text":113,"@type":109},"Good Samaritan Society-Pipestone, located at 1311 North Hiawatha, Pipestone, MN 56164, with CMS Certification Number (CCN) 245591.",{"name":115,"@type":106,"acceptedAnswer":116},"What is the recertification recommendation and the effective date?",{"text":117,"@type":109},"Based on substantial compliance, the Minnesota Department of Health recommends to CMS that the facility be recertified for Medicare and Medicaid participation. The document states the facility is certified effective July 2, 2018 for 90 skilled nursing facility/nursing facility beds.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},263505,1790054065,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},549768064622,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES  \nMEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: Y54L  \nPART I-TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00455  \n\n| 1. MEDICARE/MEDICAID PROVIDER NO.\u003Cbr>(L1) 245591\u003Cbr>2. STATE VENDOR OR MEDICAID NO.\u003Cbr>(L2) 108042300 |  | 3. NAME AND ADDRESS OF FACILITY\u003Cbr>(L3) GOOD SAMARITAN SOCIETY-PIPESTONE\u003Cbr>(L4) 1311 NORTH HIAWATHA\u003Cbr>(L5) PIPESTONE, MN (L6) 56164 |  |  |  |  |  |  | 4. TYPE OF ACTION:  7 (L8)\u003Cbr>1. Initial 2. Recertification\u003Cbr>3. Termination 4. CHOW\u003Cbr>5. Validation 6. Complaint\u003Cbr>7. On-Site Visit 9. Other\u003Cbr>8. Full Survey After Complaint |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9)\u003Cbr>6. DATE OF SURVEY 07/25/2018 (L34)\u003Cbr>8. ACCREDITATION STATUS:   (L10) |  | 7. PROVIDER/SUPPLIER CATEGORY |  |  |  |  |  02  (L7)\u003Cbr>13 PTIP\u003Cbr>14 CORF\u003Cbr>15 ASC\u003Cbr>16 HOSPICE | 22 CLIA |  |\n|  |  | 01 Hospital\u003Cbr>02 SNF/NF/Dual\u003Cbr>03 SNF/NF/Distinct\u003Cbr>04 SNF |  | 05 HHA\u003Cbr>06 PRTF 07 X-Ray\u003Cbr>08 OPT/SP | 09 ESRD\u003Cbr>10 NF\u003Cbr>11 ICF/IID\u003Cbr>12 RHC |  |  |  |  |\n|  |  |  |  |  |  |  |  |  | FISCAL YEAR ENDING DATE: (L35)\u003Cbr>09/30 |\n| 0 Unaccredited\u003Cbr>2 AOA | 1 TJC\u003Cbr>3 Other |  |  |  |  |  |  |  |  |\n| 11. .LTC PERIOD OF CERTIFICATION\u003Cbr>From (a) :\u003Cbr>To (b) : |  | 10.THE FACILITY IS CERTIFIED AS: |  |  |  |  |  |  |  |\n|  |  | x | A. In Compliance With Program Requirements |  | And/Or Approved Waivers OfThe Following Requirements:\u003Cbr>2. Technical Personnel 6. Scope of Services Limit |  |  |  |  |\n|  |  | Compliance Based On:   3. 24 Hour RN   7. Medical Director |  |  |  |  |  |  |  |\n| 12.Total Facility Beds 90 (L18) |  |   1. Acceptable POC   4. 7-Day RN (Rural SNF)   8. Patient Room Size |  |  |  |  |  |  |  |\n| 13.Total Certified Beds 90 (L17) |  |   5. Life Safety Code   9. Beds/Room\u003Cbr>B. Not in Compliance with Program |  |  |  |  |  |  |  |\n|  |  | Requirements and/or Applied Waivers: * Code: A (L12) |  |  |  |  |  |  |  |\n| 14. LTC CERTIFIED BED BREAKDOWN\u003Cbr>18 SNF 18/19 SNF 19 SNF ICF IID 90\u003Cbr>(L37) (L38) (L39) (L42) (L43) |  |  |  |  |  | 15. FACILITY MEETS\u003Cbr>1861 (e) (1) or 1861 (j) (1): (L15) |  |  |  |\n\n16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):  \n\n| 17. SURVEYOR SIGNATURE\u003Cbr> Nicole Osterloh, Supervisor  | Date :\u003Cbr>10/15/2018\u003Cbr>(L19) | 18. STATE SURVEY AGENCY APPROVAL Date: |  |\n| --- | --- | --- | --- |\n|  |  | Kamala Fiske-Downing, Enforcement Specialist 10/15/2018 | (L20) |\n\nPART II-TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY  \n19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL 21. 1. Statement of Financial Solvency (HCFA-2572) RIGHTS ACT: 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)  \n  1. Facility is Eligible to Participate 3. Both of the Above :  \n  2. Facility is not Eligible ~~ ~~  \n(L21)  \n\n| 22. ORIGINAL DATE | 23. LTC AGREEMENT 24. LTC AGREEMENT | 26. TERMINATION ACTION: | (L30) |\n| --- | --- | --- | --- |\n| OF PARTICIPATION\u003Cbr>12/01/1991 | BEGINNING DATE ENDING DATE | VOLUNTARY  00 \u003Cbr>01-Merger, Closure | INVOLUNTARY\u003Cbr>05-Fail to Meet Health/Safety |\n| (L24) | (L41) (L25) | 02-Dissatisfaction W/ Reimbursement 03-Risk of Involuntary Termination 04-Other Reason for Withdrawal | 06-Fail to Meet Agreement\u003Cbr>OTHER\u003Cbr>07-Provider Status Change |\n| 25. LTC EXTENSION DATE: | 27. ALTERNATIVE SANCTIONS\u003Cbr>A. Suspension of Admissions: |  |  |\n| (L27) | (L44)\u003Cbr>B. Rescind Suspension Date:\u003Cbr>(L45) |  | 00-Active |\n| 28. TERMINATION DATE: | 29. INTERMEDIARY/CARRIER NO.\u003Cbr>00140 | 30. REMARKS |  |\n|  | (L28) (L31) |  |  |\n| 31. RO RECEIPT OF CMS-1539 | 32. DETERMINATION OF APPROVAL DATE\u003Cbr>(L32) (L33) |  |  |\n|  |  | DETERMINATION APPROVAL |  |\n\nFORM CMS-1539 (7-84) (Destroy Prior Editions) 020499  \nP r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s CMS Certification Number (CCN): 245591  \nJuly 30, 2018  \nMs. Crystal","cbCaiayIXFY4n4yK","https://ap.wps.com/l/cbCaiayIXFY4n4yK","pdf",859484,37,"English","# Medicare/Medicaid Certification and Transmittal (CMS-1539)\n## Part I - State Survey Agency Information\n## Part II - HCFA Regional Office/Single State Agency Determination\n## Facility Recertification Letter","[{\"question\":\"What does the CMS-1539 Medicare/Medicaid certification transmittal cover?\",\"answer\":\"It compiles facility identifiers, certification-related actions, survey and effective dates, bed counts, and state survey information, then supports a CMS participation determination. The included letter recommends recertification based on substantial compliance.\"},{\"question\":\"Which facility is listed in the document?\",\"answer\":\"Good Samaritan Society-Pipestone, located at 1311 North Hiawatha, Pipestone, MN 56164, with CMS Certification Number (CCN) 245591.\"},{\"question\":\"What is the recertification recommendation and the effective date?\",\"answer\":\"Based on substantial compliance, the Minnesota Department of Health recommends to CMS that the facility be recertified for Medicare and Medicaid participation. The document states the facility is certified effective July 2, 2018 for 90 skilled nursing facility/nursing facility beds.\"}]","CMS-1539 Medicare/Medicaid Recertification Transmittal ID Y54L | PDF",1789371717,13]