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PRINTED: 12/22/2022 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:COBBLESTONE CROSSINGS HEALTH CAMPUS
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How to fill out statement of deficiencies form
How to fill out statement of deficiencies form
01
Review the specific requirements and guidelines for filling out the statement of deficiencies form.
02
Gather all relevant documentation and evidence to support the deficiencies identified.
03
Clearly describe each deficiency, including the specific regulation or standard that was not met.
04
Provide detailed explanations and examples for each deficiency to demonstrate understanding and compliance.
05
Develop a plan of correction for each deficiency, outlining steps to address and resolve the issues identified.
06
Submit the completed statement of deficiencies form to the appropriate regulatory agency for review and follow-up.
Who needs statement of deficiencies form?
01
Healthcare facilities such as hospitals, nursing homes, and home health agencies that are subject to regulatory oversight and accreditation requirements.
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What is statement of deficiencies form?
The Statement of Deficiencies form is a document used to report any non-compliance issues or deficiencies found during a survey or inspection.
Who is required to file statement of deficiencies form?
Healthcare facilities such as nursing homes, hospitals, and clinics are required to file the Statement of Deficiencies form.
How to fill out statement of deficiencies form?
The form should be filled out accurately, providing details of the deficiencies found, their location, and a plan for correction.
What is the purpose of statement of deficiencies form?
The purpose of the form is to document and address any non-compliance issues in healthcare facilities to ensure patient safety and quality of care.
What information must be reported on statement of deficiencies form?
Information such as the specific deficiencies found, their severity, and the plan of correction must be reported on the form.
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