CMS Pub. 100-10, ch. 9, § 9045.1.1

The QIO report must include at least the following information:

1. Identification of the practitioner or other person and, when applicable, the name of

the director, administrator, or owner of the entity involved;

2. The type of health care services involved;

3. A description of each failure to comply with an obligation, including specific dates,

places, circumstances, and other relevant facts;

4. Pertinent documentary evidence;

5. Copies of written correspondence, including reports of conversations with the

practitioner or other person about the violation and, if applicable, a copy of the

verbatim transcript of the meeting with the practitioner or other person;

6. The QIO’s finding that an obligation under §1156(a) of the Act has been violated,

that the violation is substantial and has occurred in a substantial number of cases,

or is gross and flagrant;

7. A case-by-case analysis and evaluation of any additional information provided by

the practitioner or other person in response to the QIO’s initial finding;

8. A copy of the CAP that the QIO developed and documentation of the results of the

plan;

9. The number of admissions by the practitioner or other person the QIO reviewed

during the period in which the violation(s) was identified;

10. The professional qualifications of QIO reviewers; and

11. The QIO sanction recommendation.