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PRINTED: 04/25/2023 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 relevant information about the complaint, including the date, time, and specific details of the issue.
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An unannounced onsite complaint is a formal grievance filed by an individual or organization against another party for non-compliance or violation of regulations or policies.
Any individual or organization who has witnessed or experienced a violation or non-compliance is required to file an unannounced onsite complaint.
To fill out an unannounced onsite complaint, one must provide detailed information about the incident, including date, time, location, parties involved, and any supporting evidence.
The purpose of an unannounced onsite complaint is to address and rectify instances of non-compliance or violations to ensure a safe and fair environment for all parties involved.
The information that must be reported on an unannounced onsite complaint includes details of the incident, supporting evidence, contact information of parties involved, and any relevant documents.
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