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PRINTED 05/01/2017 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER VIBRA HOSPITAL OF FORT WAYNE X4 ID PREFIX TAG A. 5-2 Infection Control Indiana Hospital Licensure Rules. QA 4/28/17 jlh LABORATORY DIRECTOR S OR PROVIDER/SUPPLIER REPRESENTATIVE S SIGNATURE STATE FORM TITLE XZMF11 X6 DATE If continuation sheet 1 of 1. BUILDING X3 DATE SURVEY COMPLETED B. WING 012132 NAME OF PROVIDER OR SUPPLIER X2...

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