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PRINTED: 10/31/2017
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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How to fill out and investigation of complaint
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Gather all necessary information related to the complaint, including details of the incident, witnesses, and any supporting documents.
02
Identify the parties involved and their roles in the complaint.
03
Assign a neutral investigator to conduct the investigation.
04
Conduct interviews with the parties involved and any witnesses to gather more information.
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Review any relevant policies or laws related to the complaint.
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Document all findings and conclusions of the investigation.
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Determine appropriate actions to address the complaint and prevent future incidents.
Who needs and investigation of complaint?
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Any organization or company that receives a complaint of misconduct or violation of policies.
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Individuals who want to address issues of discrimination, harassment, or other inappropriate behavior.
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