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PRINTED: 02/23/2015 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X3) DATE SURVEY COMPLETED12/16/2014STREET
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What is this visit was for?
This visit is for conducting a routine inspection of the facilities.
Who is required to file this visit was for?
The visit report must be filed by the facility manager or designated personnel.
How to fill out this visit was for?
The visit report should be filled out electronically using the provided template.
What is the purpose of this visit was for?
The purpose of this visit is to ensure compliance with safety and health regulations.
What information must be reported on this visit was for?
The report must include details of any violations found, corrective actions taken, and follow-up procedures.
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