42 CFR §1004.80

1. (a)Manner of reporting. If the violation(s) identified by the QIO have not been resolved, it must submit a report and recommendation to the OIG at the field office with jurisdiction.
2. (b)Content of report. The QIO report must include the following information—
   1. (1)Identification of the practitioner or other person and, when applicable, the name of the director, administrator or owner of the entity involved;
   2. (2)The type of health care services involved;
   3. (3)A description of each failure to comply with an obligation, including specific dates, places, circumstances and other relevant facts;
   4. (4)Pertinent documentary evidence;
   5. (5)Copies of written correspondence, including reports of conversations with the practitioner or other person regarding the violation and, if applicable, a copy of the verbatim transcript of the meeting with the practitioner or other person;
   6. (6)The QIO's finding that an obligation under section 1156(a) of the Act has been violated and that the violation is substantial and has occurred in a substantial number of cases or is gross and flagrant;
   7. (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. (8)A copy of the CAP that was developed and documentation of the results of such plan;
   9. (9)The number of admissions by the practitioner or other person reviewed by the QIO during the period in which the violation(s) were identified;
   10. (10)The professional qualifications of the QIO's reviewers; and
   11. (11)The QIO's sanction recommendation.
3. (c)QIO recommendation. The QIO must specify in its report—
   1. (1)The sanction recommended;
   2. (2)The amount of the monetary penalty recommended, if applicable;
   3. (3)The period of exclusion recommended, if applicable;
   4. (4)The availability of alternative sources of services in the community, with supporting information; and
   5. (5)The county or counties in which the practitioner or other person furnishes services.