NC DHSR-4204 2014 free printable template
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DHSR-4204 Rev. 01/14 Page 1 SCOPE OF SERVICES In the columns below check each service offered through this site. Licensure based upon deemed status cannot be completed without full disclosure. DHSR-4204 Rev. 01/14 Page 2 ACCREDITING ORGANIZATION JCAHO Joint Commission on Accreditation for Healthcare Organizations CHAP Nat l League for Nursing NCHC Nat l Home Caring Council ACHC Accreditation Commission for Home Care Inc. Other EXP DATE HOME CARE AGENCY APPLICANTS If Medicare Certified Home...
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How to fill out NC DHSR-4204
How to fill out NC DHSR-4204
01
Download the NC DHSR-4204 form from the official North Carolina Division of Health Service Regulation website.
02
Read the instructions carefully before starting to fill out the form.
03
Provide your facility's name and address at the top of the form.
04
Fill in the contact information for the facility administrator or responsible person.
05
Complete the section concerning the type of services your facility provides.
06
Indicate any licensing or certifications held by the facility.
07
Review the compliance history and provide accurate information regarding any violations or citations.
08
Include the email address and phone number for further contact.
09
Sign and date the form at the bottom before submission.
10
Submit the completed form via mail or electronically as per the instructions provided.
Who needs NC DHSR-4204?
01
The NC DHSR-4204 form is required for healthcare facilities seeking to report their operational status and compliance.
02
It is needed by facility administrators or operators for licensing, certification, and regulatory compliance purposes.
03
Healthcare facilities such as assisted living, nursing homes, and other care facilities are required to complete this form.
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What is the staffing ratio for assisted living in NC?
At least one staff person is required for every eight residents on the first and second shift, plus 1 hour of staff time for each additional resident; and one staff person for every ten residents on the third shift, plus 0.8 hour of staff time for each additional resident.
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How to become a nurse in North Carolina Get a high school diploma. Enroll in a nursing program. Complete your clinicals. Submit a license application. Pass the NCLEX. Complete other requirements and retest if needed. Maintain your license.
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Nurses who live in North Carolina no longer obtain (or renew) a license in any of the other States that have enacted the interstate compact. A nurse who resides in our State and holds an unencumbered North Carolina nursing license will have the 'privilege to practice' in any of the other Compact States.
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It can take four weeks or more to receive your new North Carolina nursing license, but you may be eligible for a temporary nursing license while your application is in process. Talk to a recruiter about your assignment needs.
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Who Is Eligible? Any low-income adult over the age of 65 and living, or planning to live in an assisted living facility is eligible. Although Special Assistance is a form of supplemental insurance (SI), you do not have to already be receiving SI, but should be eligible.
What is a nursing pool license North Carolina?
Nursing Pool Refers To Any Person, Firm, Corporation, Partnership Or Association Engaged For Hire In The Business Of Providing Or Procuring Temporary Employment In Health Care Facilities For Nursing Personnel, Including Nurses, Nursing Assistants, Nurses Aides And Orderlies.
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What is NC DHSR-4204?
NC DHSR-4204 is a form used in North Carolina for the reporting of certain data related to healthcare facilities, such as patient safety events or adverse events.
Who is required to file NC DHSR-4204?
Healthcare providers and facilities that are licensed under North Carolina regulations are required to file NC DHSR-4204 when they experience reportable events.
How to fill out NC DHSR-4204?
To fill out NC DHSR-4204, gather necessary data regarding the incident, complete each section of the form with accurate information, and submit it to the appropriate department by the established deadlines.
What is the purpose of NC DHSR-4204?
The purpose of NC DHSR-4204 is to facilitate the monitoring of patient safety and quality of care in healthcare facilities, as well as to ensure compliance with state regulations.
What information must be reported on NC DHSR-4204?
NC DHSR-4204 requires reporting information such as the date of the event, details of the incident, the individuals involved, the outcomes, and any actions taken in response to the event.
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