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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES OMB NO. 09380391(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:(X2)

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What is this visit was for?

This visit was for a routine inspection.

Who is required to file this visit was for?

The designated compliance officer is required to file this visit.

How to fill out this visit was for?

The visit should be filled out electronically using the designated form.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with regulations.

What information must be reported on this visit was for?

The information to be reported includes date of visit, findings, and corrective actions taken.

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