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PRINTED: 07/14/2021 FORM APPROVEDOffice of Health Facility Licensure and Certification STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:NEW BEGINNINGS

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How to fill out statement of deficiencies and

01

Understand the requirement and purpose of the statement of deficiencies

02

Review regulations and guidelines related to deficiencies

03

Identify areas of non-compliance

04

Document observations and findings accurately

05

Develop a plan of correction to address deficiencies

Who needs statement of deficiencies and?

01

Healthcare facilities such as hospitals, nursing homes, and assisted living facilities

02

Compliance officers and quality assurance professionals

03

Accrediting agencies and regulatory bodies

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What is statement of deficiencies?

Statement of deficiencies is a detailed report outlining any violations or areas of non-compliance with regulations or standards in a certain facility or organization.

Who is required to file statement of deficiencies?

The entity responsible for the facility or organization is required to file the statement of deficiencies.

How to fill out statement of deficiencies?

To fill out the statement of deficiencies, the responsible party must detail the violations or non-compliance issues found, along with corrective actions taken or planned.

What is the purpose of statement of deficiencies?

The purpose of the statement of deficiencies is to ensure that facilities or organizations are meeting regulatory requirements and providing safe and quality services.

What information must be reported on statement of deficiencies?

The statement of deficiencies must include detailed information about any violations or non-compliance issues, along with the corrective actions planned or taken.

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