Get the free NC DHSR NHLCS: Statement of Deficiency and Plan ... - ncdhhs

PRINTED: 08/28/2019 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

How to fill out nc dhsr nhlcs statement

How to fill out nc dhsr nhlcs statement

1. Step 1: Retrieve the NC DHSR NHLCS statement form from the official website or request a copy from the North Carolina Department of Health and Human Services.
2. Step 2: Begin filling out the form by providing your personal details, such as your name, contact information, and job title.
3. Step 3: Specify the facility or organization you belong to, including its name, address, and any relevant identification number.
4. Step 4: Answer the questions regarding the description and characteristics of the facility or organization. Provide relevant details about its services, capacity, and ownership type.
5. Step 5: Complete the sections related to compliance with federal certification and state licensure requirements. Include any certifications or licenses held by the facility or organization.
6. Step 6: Provide information about the facility's organizational structure and governance, including the names and positions of its administrators and board members.
7. Step 7: Answer the questions related to risk management and quality improvement policies and practices in place at the facility.
8. Step 8: Describe the facility's financial resources, including its operating budget and sources of funding.
9. Step 9: Include any additional information or supporting documents that may be required or relevant to the statement.
10. Step 10: Review the completed form for accuracy and ensure all required fields are filled appropriately.
11. Step 11: Sign and date the form, certifying the accuracy of the information provided.
12. Step 12: Submit the filled-out form to the designated recipient as instructed on the form or by the North Carolina Department of Health and Human Services.

Who needs nc dhsr nhlcs statement?

1. Any individual or organization operating a facility or organization in North Carolina that requires certification or licensure from the North Carolina Department of Health and Human Services needs the NC DHSR NHLCS statement.
2. Healthcare facilities, long-term care facilities, assisted living facilities, home care agencies, hospices, and other similar entities would typically need to provide this statement as part of the licensure or certification process.

For pdfFiller’s FAQs

Can I create an electronic signature for signing my nc dhsr nhlcs statement in Gmail?

When you use pdfFiller's add-on for Gmail, you can add or type a signature. You can also draw a signature. pdfFiller lets you eSign your nc dhsr nhlcs statement and other documents right from your email. In order to keep signed documents and your own signatures, you need to sign up for an account.

How can I edit nc dhsr nhlcs statement on a smartphone?

You can do so easily with pdfFiller’s applications for iOS and Android devices, which can be found at the Apple Store and Google Play Store, respectively. Alternatively, you can get the app on our web page: https://edit-pdf-ios-android.pdffiller.com/. Install the application, log in, and start editing nc dhsr nhlcs statement right away.

How do I edit nc dhsr nhlcs statement on an Android device?

With the pdfFiller Android app, you can edit, sign, and share nc dhsr nhlcs statement on your mobile device from any place. All you need is an internet connection to do this. Keep your documents in order from anywhere with the help of the app!