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US · guidance

CMS Pub. 100-16, ch. 21, § 50.5.3

Enforcing Disciplinary Standards

activein force · 2026-08-25 – presentas-observed

42 C.F.R. §§ 422.503(b)(4)(vi)(E), 423.504(b)(4)(vi)(E)

Sponsors must be able to demonstrate to CMS that disciplinary standards are enforced in

a timely, consistent and effective manner. Records must be maintained for a period of 10

years for all compliance violation disciplinary actions, capturing the date the violation

was reported, a description of the violation, date of investigation, summary of findings,

disciplinary action taken and the date it was taken. Sponsors should periodically review

these records of discipline to ensure that disciplinary actions are appropriate to the

seriousness of the violation, fairly and consistently administered and imposed within a

reasonable timeframe. Sponsors may consider including compliance as a measure on an

individual’s annual performance review. In addition, a best practice followed by some

sponsors is to publish de-identified disciplinary action in employee publications, such as

a newsletter, in order to demonstrate to employees that disciplinary action is imposed for

violations.

History

(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07- 20-12)

Provenance

Source
cms.gov
Retrieved
2026-08-25
Edition
iom-2026-08-25
Content hash
6aff4f37d85349196fb78d95336d14ab6216d4d7ca53cd2e83e8450714b6f92a
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