Wound Pros Arizona, DAB CR6251 (2023)

DECISION

The Centers for Medicare & Medicaid Services (CMS), through an administrative contractor, National Supplier Clearinghouse (NSC), revoked the enrollment of Wound Pros Arizona (Petitioner) in the Medicare program as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).  NSC concluded, based on two attempted site inspections of Petitioner’s offices, that Petitioner was not operational during the hours of operation identified by Petitioner on its Medicare enrollment application. 

Petitioner asserts that it was operational during the attempted site visits.  Petitioner argues that Petitioner primarily provides physician services to patients at their homes and only supplies limited DMEPOS products (primarily bandages) to the patients it treats.  Therefore, Petitioner posits that its office does not need to be open or staffed at any specific time or day. 

As explained below, I affirm the revocation of Petitioner’s Medicare enrollment as a DMEPOS supplier because an NSC inspector confirmed that Petitioner’s qualified practice location (i.e., the physical office location Petitioner identified on its Medicare enrollment application) was not open to the public on days and at times when Petitioner was to be open to the public (as indicated on a Medicare enrollment application).  As a result, Petitioner’s Medicare enrollment was subject to revocation because Petitioner was not considered “operational” under the regulations. 

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I. Background

Petitioner was enrolled in the Medicare program as a DMEPOS supplier.  In a March 1, 2022 notice of initial determination, NSC revoked Petitioner’s Medicare enrollment as of October 25, 2021.  CMS Ex. 3 at 1, 4, 7.  NSC identified the following reason for the revocation:  

42 CFR §424.535(a)(5) – On Site Review.  Upon on-site review or other reliable evidence, CMS determines that the provider or supplier is either of the following: 
(i) No longer operational to furnish Medicare-covered items or services. 
(ii) Otherwise fails to satisfy any Medicare enrollment requirement. 

Wound Pros Arizona is no longer operation to furnish Medicare covered items or services.  A site visit conducted on October 25, 2021 and October 28, 2021, at 3651 E Baseline Rd, Ste E230, Gilbert, AZ 85234-2689, revealed your office was closed during your disclosed hours of operation.  Thus, you are considered to be in violation of all supplier standards defined in 42 CFR 424.57(c) and pursuant to 424.535(g), the revocation is effective the date CMS determined that you were no longer operational. 

Based upon a review of the facts, we have determined that your facility is not operational to furnish Medicare covered items and services.  Thus, you are considered to be in violation of 42 CFR §§ 424.535(a)(5), all supplier standards defined in 42 CFR 424.57(c) and pursuant to 424.535(g), the revocation is effective the date CMS determined that you were no longer operational. 

CMS Ex. 3 at 1, 4, 7­.  NSC barred Petitioner from reenrollment in the Medicare program for a period of three years, effective 30 days from the postmark date on the letter.  CMS Ex. 3 at 3, 6, 9. 

Petitioner requested that NSC reconsider the revocation, stating in part: 

[Petitioner] is a wound care practice that specializes in treating advanced wound care to patients in their homes, hospices, or skilled nursing facilities.  We do not see patients at the office 3651 E. Baseline Rd, Ste E320, Gilbert AZ

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85234-2689, which is used for administrative purposes and storage of DME supplies only. 

Furthermore, we are also a physician-owned Medicare supplier.  This means we only supply DME items (wound care/surgical dressings) to our own patients in our practice as a part of their treatment plan.  These items are usually dispensed at the bedside or shipped to the patient’s homes. 

We have two full-time clinicians that see up to 15 patients a day and we are growing rapidly. 

The days the inspector came to our office we happened to have all our staff out in the field seeing patients, and due to COVID restrictions, we had a limited front desk staff. 

CMS Ex. 2 at 1, 3; see CMS Ex. 2 at 45.  Petitioner also submitted various documents in support of its reconsideration request.  CMS Ex. 2 at 7-59. 

On April 25, 2022, an NSC hearing officer issued an unfavorable reconsidered determination upholding the revocation of Petitioner’s Medicare enrollment.  CMS Ex. 1.  After summarizing the facts and Petitioner’s reconsideration request, the NSC hearing officer decided the following: 

Based on the failed site visits conducted on October 25 and 28, 2021, NSC finds that Wound Pros Arizona’s Medicare enrollment was properly revoked pursuant § 424.535(a)(5).  Wound Pros Arizona has not provided a verifiable explanation for their noncompliance with 42 C.F.R. § 424.535(a)(5) as the site visit attempts on October 25 and 28, 2021, were unsuccessful and the NSC was not able to verify compliance with the supplier standards and therefore determined that the facility was not operational during attempted visits to furnish Medicare covered items and services.  After carefully reviewing the submitted documentation, the NSC cannot grant Wound Pros Arizona access to the Medicare Trust Fund by way of a Medicare number. 

CMS Ex. 1 at 4. 

On June 27, 2022, Petitioner requested a hearing by an administrative law judge to dispute the reconsidered determination.  On July 1, 2022, the Civil Remedies Division

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acknowledged receipt of the hearing request and issued my Standing Prehearing Order (SPO), which provide the parties with procedures and dates for the filing of prehearing exchanges. 

On August 5, 2022, CMS filed a prehearing brief and motion for summary judgment (CMS Br.) along with seven proposed exhibits.  On September 9, 2022, Petitioner filed a prehearing brief and opposition to summary judgment (P. Br.) and a witness list.  Petitioner did not submit any proposed exhibits.  On September 26, 2022, CMS filed an objection to Petitioner’s proposed witness. 

II. Admission of Evidence

I admit all of CMS’s proposed exhibits, without objection.  See SPO ¶ 10; CRD Procedures § 14(e). 

III. Decision on the Record

Petitioner submitted a witness list in which it proposed that one witness testify in this case.  Petitioner did not submit the written direct testimony for this witness.  CMS objected to the witness because Petitioner did not comply with the SPO’s requirement that the parties submit, as proposed exhibits with their prehearing exchange, the written direct testimony for all witnesses.  Petitioner did not respond to that objection. 

I sustain CMS’s objection to Petitioner’s witness.  I directed the parties to submit, with their prehearing exchanges, the written direct testimony for all witnesses that the parties wanted to present in this case.  SPO ¶ 7(d)(iv); CRD Procedures § 16(b).  Specifically, the written direct testimony had to be either in the form of an affidavit or signed under penalty of perjury, and the parties had to submit written direct testimony as proposed exhibits.  SPO ¶ 11; CRD Procedures §§ 16(b), 19(b).  Petitioner did not submit written direct testimony for its witness, who, according to the witness list, is “a principle of Petitioner Wound Pros.”  Further, although Petitioner has had months to respond to CMS’s objection or seek to submit the written direct testimony late, Petitioner has filed nothing. 

CMS submitted a report by an NSC site inspector, which the site inspector signed under penalty of perjury.  CMS Ex. 5 at 4.  Under the SPO, a party who wants to cross-examine a witness must affirmatively request to cross-examine that witness.  SPO ¶ 12; CRD Procedures § 19(b); Vandalia Park, DAB No. 1940 (2004); Pac. Regency Arvin, DAB No. 1823 at 8 (2002) (holding that the use of written direct testimony for witnesses is permissible so long as the opposing party has the opportunity to cross‑examine those witnesses).  However, Petitioner did not request to cross-examine the site inspector. 

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There is no need to hold an in-person hearing in this case.  I stated in the SPO that I would only hold a hearing if a party files admissible written direct testimony and the opposing party requests to cross-examine the witness.  SPO ¶ 13; CRD Procedures § 19(b).  Petitioner did not file written direct testimony and did not request to cross-examine CMS’s site inspector.  Therefore, I decide this case based on the written record.  SPO ¶ 14; CRD Procedures § 19(d). 

IV. Issue

Whether CMS had a legitimate basis to revoke Petitioner’s Medicare billing privileges under 42 C.F.R. § 424.535(a)(5).¹

V. Jurisdiction

I have jurisdiction to decide this issue.  42 C.F.R. §§ 498.3(b)(17), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8); 42 C.F.R. §§ 424.545(a), 498.1(g). 

VI. Findings of Fact

1. On October 31, 2020, NSC received an electronically filed Medicare enrollment application from Petitioner.  Petitioner indicated the following reason for submitting the enrollment application:  “A DMEPOS Supplier is enrolling in the Medicare program for the first time.”  CMS Ex. 4 at 1. 
2. The October 31, 2020 enrollment application indicated that Petitioner’s “Primary Supplier Type” was “Physician – General Practice” and that it was “exempt from DMEPOS accreditation based on supplier type.”  CMS Ex. 4 at 3. 
3. The October 31, 2020 enrollment application stated that Petitioner’s physical address was 1910 S Stapley Dr., Suite 221, Mesa, AZ 85204-6680.  CMS Ex. 4 at 2. 
4. The October 31, 2020 enrollment application indicated that the “DME [Durable Medical Equipment] Hours of Operation” were 9:00 a.m. to 5:00 p.m., Monday

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4. through Friday, and “Total Hours Available to the Publicly Weekly:  160.”²  CMS Ex. 5 at 3. 
5. In a November 20, 2020 notice, NSC approved Petitioner’s enrollment in the Medicare program, effective November 18, 2020.  The notice indicated that Petitioner’s physical address was 1910 S Stapley Dr., Suite 221, Mesa, AZ 85204.  CMS Ex. 4 at 27.  
6. At some time prior to November 4, 2021, Petitioner submitted a Medicare enrollment application to change its enrollment information.  See CMS Ex. 2 at 7.  
7. In a November 4, 2021 notice, NSC approved Petitioner’s “Change of Information (COI) application” and indicated that Petitioner’s “Storage Location Address” had been changed.  CMS Ex. 2 at 7.  The notice now listed Petitioner’s “Physical Address Location” as 3651 E BASELINE RD STE E320 GILBERT ARIZONA 85234-2689.”³  CMS Ex. 2 at 7. 
8. On October 25, 2021, at 9:45 a.m., and October 28, 2021, at 1:15 p.m., a site inspector with NSC arrived at 3651 East Baseline Road, Gilbert, Arizona 85234, to conduct an unannounced site inspection of Petitioner’s practice location.  CMS Ex. 5 at 1.  For both visits, the inspector observed that Petitioner’s office was in an office building.  CMS Ex. 5 at 1.  The inspector also noted that Petitioner’s office was not open for business, did not appear to have staff present, had no business hours posted, and did not appear to be operational (as defined in the regulations).⁴  CMS Ex. 5 at 2. 

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9. Regarding the October 25, 2021 site visit, the inspector’s report stated the following:  “The office was not open, and the door was locked.  There was a Ring door bell on the wall.  I pushed the button.  Edger Flores answered.  He stated that the office was not open because the staff were out of town setting up another lab.  He asked for my phone number, I said he should contact the CMS or their [Medicare contractor].”  CMS Ex. 5 at 4.  The inspector took photographs outside Petitioner’s practice location.  CMS Ex. 5 at 3, 5-6. 
10. Regarding the October 28, 2021 site visit, the inspector’s report stated the following:  “The door was locked.  I rang the Ring door bell twice.  A person (no name provided) answered the door, and he said the staff was out of town.  I told him to contact the CMS or [Medicare contractor] to explain the circumstances of their absence.”  CMS Ex. 5 at 4. 

VII. Conclusions of Law

1. Based on two attempted site inspections, Petitioner’s practice location was not “operational,” as that term is defined in 42 C.F.R. § 424.502. 
2. CMS had a legitimate basis to revoke Petitioner’s Medicare enrollment because it was not operational to furnish Medicare-covered items or services under 42 C.F.R. § 424.535(a)(5)(i). 

VIII. Analysis

The Secretary of Health and Human Services (Secretary) has the authority to establish enrollment requirements for providers and suppliers.  42 U.S.C. § 1395cc(j).  In order to enroll and obtain Medicare billing privileges, a provider or supplier must file an enrollment application that discloses a variety of information to CMS, including its “practice location.”  42 C.F.R. §§ 424.505, 424.510. 

After the provider or supplier submits the enrollment application, CMS may conduct a site visit of the provider or supplier’s practice location to verify compliance with Medicare enrollment requirements.  42 C.F.R. § 424.510(d)(8).  One purpose of a site

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visit is to determine whether a provider or supplier is “operational.”  42 C.F.R. § 424.510(d)(8)(i)-(ii).  A failure to be operational is a basis to deny an enrollment application.  42 C.F.R. § 424.530(a)(5)(i).  The term “operational” means: 

the provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims, and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered), to furnish these items or services. 

42 C.F.R. § 424.502 (definition of Operational).  In order “[t]o be ‘operational’ in accordance with the definition in section 424.502, a provider [or supplier], among other things, must have a ‘qualified physical practice location’ that is ‘open to the public for the purpose of providing health care related services.’”  Viora Home Health, Inc., DAB No. 2690 at 7 (2016).  A qualified physical practice location is the supplier’s address that is on file with CMS at the time of a site visit.  Foot Specialists of Northridge, DAB No. 2773 at 8-10 (2017). 

Once CMS enrolls a provider or supplier in the Medicare program, the provider or supplier must update information that it originally provided to CMS when it enrolled.  42 C.F.R. §§ 424.515, 424.516.  CMS has the authority to perform onsite inspections of a provider or supplier to verify the accuracy of the information submitted to CMS and to determine compliance with enrollment requirements.  42 C.F.R. § 424.517.  CMS’s contractors conduct site visits without notice to the providers or suppliers.  76 Fed. Reg. 5862, 5870 (Feb. 2, 2011) (“[T]he primary purpose of an unannounced and unscheduled site visit is to ensure that a provider or supplier is operational at the practice location found on the Medicare enrollment application.”)  

In addition to the general authority to establish provider and supplier enrollment requirements, the Secretary has the authority to establish supplier standards for DMEPOS suppliers.  42 U.S.C. § 1395m(j)(1)(B)(ii).  The Secretary must include in the supplier standards a requirement that all DMEPOS suppliers “maintain a physical facility on an appropriate site.”  42 U.S.C. § 1395m(j)(1)(B)(ii)(II).  The Secretary promulgated DMEPOS supplier standards at 42 C.F.R. § 424.57(c).  The supplier standards state that a DMEPOS supplier must be “open to the public a minimum of 30 hours per week,” post its hours of operation, and be “accessible and staffed during posted hours of operation.”  42 C.F.R. §§ 424.57(c)(7)(i), (c)(30)(i).  However, a physician who furnishes “items to his or her own patient(s) as part of his or her professional services” is exempt from the requirement of being open to the public for a minimum of 30 hours per week.  42 C.F.R. § 424.57(c)(30)(ii)(A). 

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A supplier is subject to revocation of its Medicare billing privileges if it violates the DMEPOS supplier standards or the regulatory requirements applicable to all suppliers.  42 C.F.R. §§ 424.57(e), 424.535(a).  Relevant to the present case, CMS may revoke a supplier’s enrollment if CMS determines, based on an on-site review or other reliable evidence, that a provider or supplier is “no longer operational to furnish Medicare-covered items or services.”  42 C.F.R. § 424.535(a)(5)(i). 

In the present case, it is undisputed that the site inspector twice attempted to conduct a site visit of the practice location that Petitioner provided on an enrollment application form.  However, the inspector was unable to complete either site visit because Petitioner’s practice location was locked, and the inspector was told that no one was present to see the inspector.  Further, the site inspector attempted these visits on days and at times when, based on the information in the enrollment application, Petitioner would be open to the public. 

These facts are sufficient for me to conclude that Petitioner was not open to the public, and, therefore, not operational.  In making this conclusion, I am mindful “that the proper inquiry is to assess the supplier’s operational status at the time of the onsite review because the intent of the applicable regulations ‘is that a supplier must maintain, and be able to demonstrate, continued compliance with the requirements for receiving Medicare billing privileges.’”  Viora, DAB No. 2690 at 7 n.7, quoting A to Z DME, LLC, DAB No. 2303 at 7 (2010).  Petitioner’s failure to be open to the public on either of the days that the inspector attempted site visits prevented the inspector from determining whether Petitioner was compliant with enrollment requirements. 

Petitioner disagrees that it was not operational.  After quoting the definition of “operational” from the regulations, Petitioner argues as follows: 

[T]he definition of “operational” is flexible and designed to accommodate different types of medical practices and delivery systems.  Here, Wound Pros is not in the business of selling DMEPOS to walk in clientele.  Rather, the public it serves is bedridden and unable to come to doctors’ offices.  Thus, the type of staffing, equipment and method of stocking supplies for Wound Pros facility-based practice is very different from that utilized by businesses that sell wheel chairs, portable toilets and crutches to Medicare beneficiaries in need of DMEPOS.  Since there has never been a single allegation of Wound Pros providing substandard care to the patients it serves, there is absolutely no evidence that it is not adequately staffed, equipped or stocked. 

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42 C.F.R. (c)(7)(i)(C) does state that offices supplying DMEPOS to Medicare beneficiaries must be “accessible and staffed during posted office hours.”  However, DMEPOS suppliers who provide items to their own patients are exempt from this requirement.  Specifically, the requirement for how long DMEPOS suppliers must keep their doors open to the public is found in 42 C.F.R. § 424.57(c)(30), which states that a DMEPOS supplier must certify that it: 

“(i) Except as specified in paragraph (c)(30)(ii) of this section, is open to the public a minimum of 30 hours per week. 

(ii) The provision of paragraph (c)(30)(i) of this section is not applicable at a practice location where  a –

(A) Physician whose services are defined in section 1848(j)(3)1 of the Act furnishes items to his or her own patient(s) as part of his or her professional service;” (Emphasis added). 

As discussed above, Wound Pros only provides surgical dressings as part of the professional physician services provided to its patients, at bedside.  Thus, there is no requirement that it post any hours of operation.  To do so would be senseless, as there is never a circumstance where one of its patients would come to the office.  The facility isn’t designed or equipped to treat patients with chronic wounds, and Wound Pros is not in the business of selling surgical dressing to the general public. 

P. Br. at 4-5. 

CMS argues that Petitioner gave notice to CMS that it would be open to the public Monday through Friday from 9:00 a.m. to 5:00 p.m. each day.  More specifically, CMS argues the following: 

Petitioner’s facility was not open to the public and therefore not operational because it was admittedly unstaffed during posted hours of operation.  As documented in the site inspection report, and confirmed by Petitioner’s Request for Reconsideration, Petitioner’s facility was not staffed or open

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during the two attempted site inspections that were conducted on October 25 and October 28, 2021. 

* * * * *

Notably, as the pictures taken during the attempted site inspections demonstrate, Petitioner did not have its hours of operation posted.  However, its enrollment application listed its business hours as Monday through Friday, 9am to 5 pm. There was no indication either via signage at the door or in the listed hours from their Medicare application that there would be any specific hours in which its offices would actually have staff present.  Petitioner does not allege that the hours in its enrollment record listed as business hours are incorrect. 

* * * * *

Petitioner’s facility was not open to the public and therefore not operational because it was regularly unstaffed during posted hours of operation.  Petitioner’s listed hours of business in its enrollment record were 9:00 am to 5:00 pm Monday through Friday.  Petitioner in its reconsideration request admitted that at the time of the site inspections it did not have a system in place for ensuring front desk coverage during its posted hours and that both clinicians were not in the office at the time of the attempted site inspections. 

The issue before the court is not whether Petitioner intended to be compliant and misunderstood the statutory language, or whether its failure to be operational and accessible to potential beneficiaries during its posted hours was for a limited time, but whether CMS correctly found that, at the time of the revocation action, Petitioner was not in compliance, and that CMS therefore had authority to revoke.  Because Petitioner explicitly admits that its employees were regularly absent from the office during posted hours of operation, Petitioner’s facility was not “open to the public” or “operational,” and its billing privileges were properly revoked pursuant to 424.535(a)(5)(i).  

The Board has held that a supplier may be revoked under 42 C.F.R. § 424.535(a)(5)(i) for failing to be operational

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when a site inspector attempts to conduct site inspections during a supplier’s posted hours of operation, and no one answers the door. 

CMS Br. at 9, 10, 12-13 (citations omitted). 

Although CMS confusingly discusses Petitioner’s posted hours of operation, when CMS also indicates none were posted, I generally agree with CMS’s argument because it revolves around the fact that the site inspector attempted two visits during days and at times when Petitioner indicated, in its enrollment application, it would be open to the public.  Further, the case referenced by CMS in the final paragraph quoted above is relevant to this case.  Similar to Petitioner’s situation, that case involved a provider (i.e., a home health agency) that sent all its personnel out to provide services to patients in their homes and left no staff at its offices.  However, the provider’s argument, “that the failure of employees on the premises to respond to the inspector’s knocking on the door was insufficient to find it non-operational,” was rejected because site inspections are intended to be unannounced.  Vamet Consulting & Medical Services, DAB No. 2778 at 7 (2017) (holding that placing the burden on a site inspector to arrange a site visit would completely frustrate the intent of the regulations). 

The present case differs from Vamet in that Petitioner appears to be exempt from the normal DMEPOS requirement that it be open to the public for a minimum of 30 hours per week.  Despite this, I conclude that this exemption does not entirely absolve Petitioner from being open to the public.  Ortho Rehab Designs Prosthetics & Orthotics, Inc., DAB No. 2591 at 5-6 (2014); Sonoma Prosthetic Eyes, DAB No. 2622 at 5-6 (2015).  Further, once Petitioner informed CMS that it would be open from 9:00 a.m. to 5:00 p.m., from Monday to Friday, Petitioner’s offices were obligated to be open during those hours. 

[A]lthough Supplier Standard 30 would have allowed Ortho to be open for less than 30 hours a week, Ortho chose to adopt Monday through Friday from 9 a.m. to 5 p.m. as its posted hours of operation (for a total of 40 hours per week).  ALJ Decision at 5-6.  Even though these hours exceeded the requirements of Supplier Standard 30, under Supplier Standard 7, once Ortho posted those hours, it needed to be “staffed and accessible” during those hours.  

Ortho, DAB No. 2591 at 6.  Although the quote above relates to a case involving Supplier Standard 7, which requires that a DMPEPOS supplier be open and accessible to the public, the essential reasoning is applicable to whether a supplier is “operational” under 42 C.F.R. § 424.535(a)(5)(i) as well.  Petitioner may not have posted its hours of operation, but it expressly informed CMS of the hours that it would be operation and open to the public on its enrollment application.  CMS can rely on the statements in the

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enrollment application because they were certified as true, correct, and complete by an authorized official on Petitioner’s behalf.  CMS Ex. 4 at 1; CMS Ex. 6 at 34. 

As stated above, the term “operational” means: 

the provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims, and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered), to furnish these items or services. 

42 C.F.R. § 424.502 (emphasis added).  In the present case, Petitioner’s “physical practice location,” as specified on the enrollment application, was not open to the public on the days and at the times specified in the enrollment application.  Therefore, CMS had a legitimate basis to revoke Petitioner’s Medicare enrollment because an on-site inspection indicated that Petitioner was not operational.  42 C.F.R § 424.535(a)(5)(i). 

IX. Conclusion

I affirm CMS’s revocation of Petitioner’s Medicare enrollment and billing privileges effective October 25, 2021. 

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Endnotes

¹  Although the parties discussed in detail a variety of DMEPOS supplier standards in 42 C.F.R. § 424.57(c), I note that NSC based Petitioner’s revocation on 42 C.F.R. § 424.535(a)(5). CMS Ex. 1 at 4. Therefore, all discussion in this decision of the DMEPOS supplier standards is not meant to imply that I uphold the revocation on any basis other than 42 C.F.R. § 424.535(a)(5).

²  Based on its hours of operation, Petitioner mistakenly indicated that it was open to the public for 160 hours per week rather than 40 hours per week.

³  There does not appear to be any dispute that Petitioner’s physical practice location was changed before November 4, 2021, to the 3651 East Baseline Road address. With its reconsideration request, Petitioner submitted the notice from NSC indicating the address change. See CMS Ex. 2 at 7. Further, the letterhead on which Petitioner’s reconsideration request was written indicates that the 3651 East Baseline Road address is Petitioner’s “Physical address.” CMS Ex. 2 at 3, 45. This is consistent with CMS’s records. CMS Ex. 7 at 1-2.

⁴  The site inspector’s report stated that Petitioner’s suite number at the 3651 East Baseline Road address was E230 instead of E320. CMS Ex. 5 at 4. The site inspector provided photographs of the building directory and Petitioner’s sign showing that suite 230 is Petitioner’s suite. CMS Ex. 5 at 5-6. The record does not include the enrollment application that Petitioner filed with its change of address. However, Petitioner’s letterhead indicated that its physical address was suite E320. CMS Ex. 2 at 3, 45. Despite this inconsistency, Petitioner did not raise this as an issue in this case or argue that the site inspector failed to locate its practice location when attempting to conduct the site visits. Therefore, I find that the site inspector made valid attempts to conduct site visits at Petitioner’s physical practice location.