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PRINTED: 06/23/2014 FORM APPROVED Illinois Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.
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Identify the areas or aspects that need to be addressed in the statement.
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Begin writing the statement by stating the deficiency clearly and concisely.
05
Provide sufficient details and evidence to support the identified deficiency.
06
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Statement of deficiencies x1 is needed by individuals or organizations who are involved in quality assurance, compliance, or regulatory activities.
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This can include auditors, inspectors, regulatory agencies, or internal quality control departments of an organization.
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The statement of deficiencies x1 is a document that identifies areas of non-compliance with regulations or standards in a specific entity.
The entity or organization that is being inspected or audited is required to file the statement of deficiencies x1.
The statement of deficiencies x1 should be filled out by detailing the specific deficiencies found, including the regulations or standards that were not met.
The purpose of the statement of deficiencies x1 is to document areas of non-compliance and create a plan for corrective action.
The statement of deficiencies x1 must report specific details of non-compliance, including the nature of the deficiency, the regulatory standard violated, and any corrective actions taken or planned.
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