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PRINTED: 09/24/2020 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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Gather all necessary information and documents for the visit

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Arrive at the designated location at the scheduled time

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Check in with the receptionist or front desk staff

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Follow any instructions provided by the staff

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Complete any required forms or paperwork accurately and completely

06

Participate in the visit as directed by the healthcare provider

07

Ask any questions or address any concerns during the visit

08

Follow up on any additional steps or recommendations given by the provider after the visit

Who needs this visit was for?

01

Individuals seeking medical assistance or guidance from a healthcare provider

02

Patients requiring a routine check-up or consultation

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Anyone in need of diagnosis, treatment, or management of a health condition

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Those seeking preventive care or health education

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What is this visit was for?

This visit is for conducting a routine inspection.

Who is required to file this visit was for?

The compliance officer is required to file this visit.

How to fill out this visit was for?

The visit report must be completed with details of observations and findings.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with regulations.

What information must be reported on this visit was for?

All findings, observations, and corrective actions taken must be reported.

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