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Get the free NC DHSR NHLCS Statement of Deficiency

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Printed: 04/15/2021 Form Approved OMB No. 09380391Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
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Obtain the NC DHSR NHLCS statement form from the appropriate website or office.
02
Fill in your personal information such as name, contact information, and license number.
03
Provide detailed information about the incident or complaint that you are reporting.
04
Include any supporting documentation or evidence with your statement.
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Sign and date the form before submitting it to the NC DHSR NHLCS office.

Who needs nc dhsr nhlcs statement?

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Healthcare facilities
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Nursing homes
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Residential care facilities
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The North Carolina Department of Health Service Regulation Nursing Home Licensure and Certification Section statement.
All nursing homes in North Carolina are required to file the nc dhsr nhlcs statement.
The nc dhsr nhlcs statement can be filled out online on the NC DHSR website or submitted via mail.
The purpose of the nc dhsr nhlcs statement is to ensure compliance with state regulations and maintain the quality of care provided by nursing homes.
The nc dhsr nhlcs statement requires information on staffing levels, resident care, facility maintenance, and financial stability.
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