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PRINTED: 01/24/2012 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 extended survey-immediate jeopardy-past

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To fill out the extended survey-immediate jeopardy-past, follow these steps:

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Start by reviewing the survey questions and instructions carefully.

03

Make sure you have all the necessary information and documentation related to the past immediate jeopardy incident.

04

Begin filling out the survey by providing the required demographic information.

05

Proceed to answer the questions regarding the specific immediate jeopardy incident in detail. Be clear and concise in your responses.

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Attach any supporting documents or evidence that can help validate your responses and provide a comprehensive understanding of the incident.

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Submit the filled-out extended survey-immediate jeopardy-past according to the designated method or to the appropriate authority.

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Keep a copy of the survey and any related documents for your records.

Who needs extended survey-immediate jeopardy-past?

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The extended survey-immediate jeopardy-past is typically required by regulatory agencies, healthcare organizations, or governing bodies responsible for monitoring and auditing healthcare facilities.

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It is needed to assess the nature of past immediate jeopardy incidents, gather essential data for analysis, and ensure compliance with regulations and standards.

03

Healthcare providers and administrators may also need to fill out this survey to address any immediate jeopardy incidents that occurred in their facilities and demonstrate efforts towards improvement and risk prevention.

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