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PRINTED: 02/20/2017 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:FAYETTE REGIONAL HEALTH SYSTEM
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How to fill out statement of deficiencies and
How to fill out statement of deficiencies and
01
To fill out a statement of deficiencies, follow these steps:
02
Start by opening the statement of deficiencies form.
03
Enter the name and contact information of the facility being inspected.
04
Identify the date and time of the inspection.
05
List the deficiency or violation that was found during the inspection.
06
Provide a detailed description of the deficiency, including any relevant facts or observations.
07
Indicate the specific regulation or standard that was violated.
08
Propose a plan of correction to address the deficiency.
09
Include any supporting documentation or evidence related to the deficiency.
10
Submit the completed statement of deficiencies to the appropriate regulatory agency.
Who needs statement of deficiencies and?
01
Statement of deficiencies is needed by regulatory agencies responsible for inspecting and monitoring facilities such as healthcare facilities, nursing homes, assisted living facilities, and other similar institutions.
02
It is also useful for facility administrators and managers to assess and address any deficiencies or violations found during inspections.
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What is statement of deficiencies and?
The statement of deficiencies is a report that outlines areas where a healthcare facility is not in compliance with regulations or standards.
Who is required to file statement of deficiencies and?
Healthcare facilities such as hospitals, nursing homes, and home health agencies are required to file statement of deficiencies.
How to fill out statement of deficiencies and?
The statement of deficiencies is typically filled out by the facility's administrators or compliance officers who are familiar with the regulations and standards.
What is the purpose of statement of deficiencies and?
The purpose of the statement of deficiencies is to identify areas of non-compliance and outline actions the facility will take to correct them.
What information must be reported on statement of deficiencies and?
The statement of deficiencies must include details on the specific deficiencies found, the regulations violated, and the corrective actions planned.
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