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This document provides a summary of deficiencies found during the survey of Friends Fellowship Community and outlines the plan of correction required to address these deficiencies.

How to fill out statement of deficiencies and

How to fill out STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

1. Read the form carefully to understand its structure and requirements.
2. Identify the areas of deficiencies within the facility or program being assessed.
3. Document each deficiency clearly, providing specific details and examples.
4. Propose a plan of correction for each deficiency, outlining steps to address and resolve the issue.
5. Assign responsibilities for implementing the plan to specific staff members or departments.
6. Set a timeline for completion of the corrections and any follow-up actions.
7. Review the entire document for accuracy and completeness before submission.
8. Submit the completed Statement of Deficiencies and Plan of Correction to the appropriate regulatory agency.

Who needs STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

1. Healthcare facilities undergoing inspections for quality and compliance.
2. Providers seeking to address identified issues and improve care standards.
3. Regulatory agencies requiring documentation of deficiencies and corrective measures.
4. Administrators and managers who need to ensure compliance with health regulations.

People Also Ask about

What are the levels of deficiency in CMS?

There are three scope levels assigned to a deficiency: isolated, pattern, or widespread. The survey agency determines the scope and severity levels for each deficiency cited on a survey.

Which of the following elements must your plan of correction include?

Element 1: How the corrective action will be accomplished for identified affected individuals. Element 2: How will other individuals with the potential to be affected or in similar situations be identified and protected. Element 3: What systemic changes will ensure that the deficient practice will not recur.

What level is a plan of correction not required for?

There are three scope levels assigned to a deficiency: isolated, pattern, or widespread. The survey agency determines the scope and severity levels for each deficiency cited on a survey.

How do you write an acceptable plan of correction?

An acceptable Plan of Correction will include both immediate corrective actions to correct the violation and long-term quality improvement actions, with each element including who is responsible, when it will be done, and what action has been or will be taken.

In which case would a facility not have to submit a plan of correction?

A facility is not required to submit a plan of correction when it has deficiencies that are isolated and have a potential for minimal harm, but no actual harm has occurred.

How long does an IJ last?

In all cases of immediate jeopardy, the provider agreement must be terminated by CMS or State Medicaid Agency no later than 23 calendar days from the last day of the survey if the immediate jeopardy is not removed.

How to write a statement of deficiency?

To write a Statement of Deficiencies, three elements must be completed: • Gather enough strong evidence. Differentiate finding and deficient practice or noncompliance. Based on a regulation/requirement, recognize what the entity failed to do. Don't wait until near the end of the survey.

For pdfFiller’s FAQs

What is STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

The Statement of Deficiencies and Plan of Correction (SOD/P) is a formal document issued by regulatory agencies, typically following an inspection, that outlines specific deficiencies found in a facility's compliance with applicable regulations. It also includes the facility's plan to address these deficiencies.

Who is required to file STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

Facilities that are subject to inspection by regulatory agencies, such as healthcare facilities, nursing homes, and other licensed entities, are required to file a Statement of Deficiencies and Plan of Correction when deficiencies are identified.

How to fill out STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

To fill out the SOD/P, facilities must carefully review the deficiencies cited by the regulatory agency, provide a detailed response for each deficiency, outline corrective actions to be taken, and establish a timeline for implementation. It is important to be specific and include measurable outcomes.

What is the purpose of STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

The purpose of the SOD/P is to document compliance issues, provide a structured plan for facilities to improve their services, ensure accountability, and protect the health and safety of individuals receiving care within the facility.

What information must be reported on STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION?

The SOD/P must include the specific deficiencies identified, the related regulatory citations, the facility's proposed corrective actions for each deficiency, the timeline for implementation, and the person responsible for overseeing the correction process.