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PRINTED: 05/12/2016 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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How to fill out original complaint investigation

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Begin by clearly stating the facts of the complaint, providing any relevant dates, times, and locations.
02
Include any supporting documents or evidence that can substantiate the complaint.
03
Clearly identify the parties involved in the complaint, including names, job titles, and departments.
04
Specify the issues or problems that the complaint pertains to, explaining them in detail and providing examples if possible.
05
Provide a timeline of events leading up to the complaint, including any previous attempts to resolve the issue.
06
Offer any possible solutions or suggestions for resolving the complaint.
07
Conclude the complaint by restating the desired outcome or resolution.
08
Sign and date the complaint, and include your contact information for further communication.

Who needs original complaint investigation?

01
Any individual or organization that has experienced or witnessed a violation, misconduct, or unfair treatment may need an original complaint investigation. This includes employees, customers, clients, students, patients, and any other parties affected by the alleged wrongdoing. Additionally, regulatory bodies, law enforcement agencies, and legal entities may also require an original complaint investigation to address potential violations.
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Original complaint investigation is the initial investigation conducted to address a complaint or concern brought forward by an individual or organization.
The responsible party or individual identified in the complaint is required to file the original complaint investigation.
The original complaint investigation can be filled out by providing detailed information about the complaint, including dates, individuals involved, and any supporting documents.
The purpose of the original complaint investigation is to address and resolve the issues or concerns raised in the complaint.
The original complaint investigation must include a summary of the complaint, details of the investigation conducted, findings, and any actions taken to address the complaint.
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