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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15G72205/10/2017FORM
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To fill out this visit, start by entering the date and time of the visit.
02
Next, provide the name and contact information of the person visited.
03
Then, describe the purpose of the visit and provide any additional details.
04
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What is this visit was for?
This visit is for a routine inspection of the facility.
Who is required to file this visit was for?
The facility owner or manager is required to file this visit.
How to fill out this visit was for?
The visit should be documented by recording the date of inspection, areas inspected, any findings, and corrective actions taken.
What is the purpose of this visit was for?
The purpose of this visit is to ensure compliance with regulations and standards.
What information must be reported on this visit was for?
Information such as inspection date, areas inspected, findings, and corrective actions must be reported.
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