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PRINTED: 04/11/2019 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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Form survey team entered is a document used to track and record information about a survey team's activities.

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Information such as the date of the survey, location, team members' names, and observations made during the survey must be reported on form survey team entered.

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