Certification - 1539 - The State Agency (SA) uses the form 1539 to certify findings to the Centers for
Medicare and Medicaid Services (CMS) Regional Office (RO) or to the State Medicaid Agency (SMA) with
respect to a facility’s compliance with health and safety requirements. Form 1539 is also a transmittal
cover sheet for the certification packet.
Correspondence - CMS - Correspondence the State Agency (SA) receives from the Centers for Medicare and
Medicaid (CMS) Regional Office (RO) regarding the facility.
Correspondence - Misc - Correspondence the State Agency (SA) receives regarding the facility that is
not of a confidential nature.
License - The facility’s license and correspondence from the Licensure Division regarding the facility’s
Survey Documents - Annual survey/inspections and any complaint investigation s, correspondence to
the facility regarding the findings and any penalties or remedies that will be imposed, and the facility’s
plan of correction of how they will correct the deficiencies.