Get the free Statement of Deficiencies (Form 2567)

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:155267(X2)

How to fill out statement of deficiencies form

How to fill out statement of deficiencies form

1. To fill out the Statement of Deficiencies form, follow these steps:
2. Begin by providing the facility name and address on the first line of the form.
3. Next, specify the CMS Certification Number (CCN) of the facility.
4. Indicate the date of the survey or investigation that led to the identification of deficiencies.
5. List each deficiency separately, with a detailed description of the problem or non-compliance.
6. Provide the regulatory reference number associated with each deficiency.
7. Include the applicable tag number(s) from the State Operations Manual (SOM) or other relevant regulations.
8. Explain the potential harm or actual harm resulting from each deficiency.
9. Offer a corrective action plan for each deficiency, stating how the issue will be resolved and prevented in the future.
10. Include a timetable for completion of the corrective actions.
11. Sign and date the form, ensuring that it is submitted within the designated timeframe.
12. Note: It is advisable to review the instructions provided by the respective regulatory agency for specific requirements.

Who needs statement of deficiencies form?

1. The Statement of Deficiencies form is required by healthcare facilities that have been surveyed or investigated by a regulatory agency such as the Centers for Medicare and Medicaid Services (CMS). This form is used to document any deficiencies or violations of regulations identified during the survey or investigation. It is necessary for facilities to complete this form to demonstrate compliance and outline their plan for resolving the deficiencies.

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What is statement of deficiencies form?

The Statement of Deficiencies form is a document used to report any deficiencies found during a survey or inspection of a facility.

Who is required to file statement of deficiencies form?

Facilities or entities that are subject to inspections or surveys are required to file the Statement of Deficiencies form.

How to fill out statement of deficiencies form?

The form should be completed by detailing each deficiency found, including the location, nature, and recommended corrective actions.

What is the purpose of statement of deficiencies form?

The purpose of the form is to document and address any deficiencies in compliance with regulations or standards.

What information must be reported on statement of deficiencies form?

The form should include details of each deficiency, the location where it was found, and the corrective actions recommended.