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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:15G38208/04/2016FORM
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How to fill out substantiated federalstate deficiency r

01
To fill out a substantiated federal state deficiency report, follow these steps:
02
Begin by providing your personal information, including your name and contact information.
03
Indicate the date and time of the incident or observation that led to the report.
04
Describe the nature of the deficiency in detail, outlining the specific violation or issue that was observed.
05
Provide any supporting evidence or documentation, such as photographs or witness statements, if available.
06
Explain the potential consequences or risks associated with the deficiency, emphasizing the need for immediate action.
07
Recommend corrective measures or actions that should be taken to address the deficiency.
08
Sign and date the report to confirm its accuracy and authenticity.
09
Submit the report to the appropriate federal or state agency or authority as instructed.

Who needs substantiated federalstate deficiency r?

01
Substantiated federal state deficiency reports are typically required by regulatory agencies or authorities responsible for overseeing specific industries or sectors.
02
Organizations and individuals subject to federal or state regulations may need to fill out these reports when they identify deficiencies or violations that need to be reported.
03
Examples of entities that may need substantiated federal state deficiency reports include healthcare facilities, educational institutions, manufacturing companies, construction firms, and environmental agencies.
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