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PRINTED: 10/01/2021 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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The document referred to is likely a form or report related to nursing home abuse advocacy, created or endorsed by the Department of Health, aimed at addressing and documenting incidents of abuse in nursing homes.
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To fill out the form, individuals should provide detailed information about the incident, including the date, location, persons involved, nature of the abuse, and any evidence or witnesses. Instructions specific to the form should be followed.
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Essential information that must be reported includes details about the victim, the perpetrator, specific incidents of abuse, any injuries sustained, and any steps taken to address the situation.
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