Reporting Findings for Standards Using Binary Scale

For all standards except 1.b, 1.c, 1.d, 2.a, 3.a and 3.b, report the findings using a binary scale. The DVC selects “Y” if the requirements for the standard or sub-standard have been completely met. The DVC should select “N” if any requirement for the standard or sub-standard wasn’t met.

CMS expects that there will be situations where the DVC finds that an SO isn’t fully compliant with specific DV standards. CMS has set up a threshold where a minimum of 90% of records are accurate, including sample or census records, source documents, policies and procedures, and data entry records, to record a "Y” finding for any standard.

DVCs apply this threshold to standards that need the review of policies and procedures when possible to quantify the adherence to or implementation of policies and procedures, as shown in Exhibit 6 of the DV Manual.

Table 19 shows examples of how to calculate this minimum threshold specifically for Sub-Standard 3.a, where the DV involves samples or the complete census of records or data values.