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PRINTED: 07/20/2021 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 such as personal details, date of incident, description of incident, etc.

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Who needs nc dghsr nhlcs statement?

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Individuals who have witnessed or been involved in an incident that falls under the jurisdiction of the NC DGHRS NHLCs (North Carolina Department of Health and Human Services Non-Hospital Care Settings) may need to fill out this statement.

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The nc dghsr nhlcs statement is a financial disclosure statement required by state law.

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Government officials, employees, and certain individuals holding public office are required to file the nc dghsr nhlcs statement.

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The purpose of the nc dghsr nhlcs statement is to provide transparency and accountability in government by disclosing potential conflicts of interest.

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