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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15540607/21/2014FORM
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Gather all relevant information and documentation related to the deficiency.
02
Clearly outline the deficiency and provide specific details.
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Who needs substantiated federalstate deficiency rel?

01
Healthcare facilities that have been found to have deficiencies during a federal or state inspection.
02
Regulatory authorities who are conducting the investigation and require documentation of substantiated deficiencies.
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Substantiated federalstate deficiency rel is a form used to report deficiencies in federal or state regulations that have been substantiated by evidence.
Entities or individuals who have identified and substantiated deficiencies in federal or state regulations are required to file the substantiated federalstate deficiency rel.
The substantiated federalstate deficiency rel must be filled out by providing detailed information about the identified deficiencies, including evidence to support the claims.
The purpose of substantiated federalstate deficiency rel is to document and report substantiated deficiencies in federal or state regulations for regulatory compliance and improvement.
Information such as the nature of the deficiency, the regulatory requirement violated, the evidence substantiating the deficiency, and any corrective actions taken must be reported on the substantiated federalstate deficiency rel.
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