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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:15C000114603/05/2013FORM

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Start by gathering all the necessary information about the visit, such as the purpose, date, time, and location.

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03

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04

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It could be for individuals attending appointments, meetings, interviews, or any other type of visitation.

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What is this visit was for?

This visit was for a routine inspection of the facilities.

Who is required to file this visit was for?

The facility manager or designated representative is required to file this visit.

How to fill out this visit was for?

The visit report must be completed and submitted online through the designated portal.

What is the purpose of this visit was for?

The purpose of this visit was to ensure compliance with safety regulations and standards.

What information must be reported on this visit was for?

The visit report must include details of any safety hazards identified, actions taken to address them, and recommendations for improvement.

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