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PRINTED: 09/15/2014 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:A. BUILDING: (X3) DATE SURVEY

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How to fill out substantiated federalstate deficiencies re

01

Review the federal and state regulations to understand the requirements for substantiated deficiencies.

02

Collect all relevant documentation and evidence to support the identified deficiencies.

03

Clearly describe each deficiency and its impact in detail.

04

Include any applicable corrective actions that have been taken to address the deficiencies.

05

Provide any supporting data or reports that validate the deficiencies.

06

Follow the required format and guidelines for submitting the substantiated federal/state deficiencies.

07

Submit the completed form or report to the appropriate regulatory authority.

08

Maintain records of the submitted deficiencies for future reference and compliance purposes.

Who needs substantiated federalstate deficiencies re?

01

Healthcare facilities and providers

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What is substantiated federalstate deficiencies re?

Substantiated federalstate deficiencies re are deficiencies in federal or state regulations that have been proven to be true through evidence.

Who is required to file substantiated federalstate deficiencies re?

The entities or individuals responsible for the deficiencies are required to file substantiated federalstate deficiencies re.

How to fill out substantiated federalstate deficiencies re?

Substantiated federalstate deficiencies re can be filled out by providing detailed information about the deficiencies, evidence supporting them, and any corrective actions taken.

What is the purpose of substantiated federalstate deficiencies re?

The purpose of substantiated federalstate deficiencies re is to address and correct regulatory violations to ensure compliance with federal or state laws and regulations.

What information must be reported on substantiated federalstate deficiencies re?

The report must include details about the deficiencies, evidence supporting the claims, any corrective actions taken, and any follow-up plans.

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