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PRINTED: 07/26/2019 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.

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How to fill out deficiencies were cited

01

Review the list of deficiencies provided

02

Identify the areas where deficiencies were cited

03

Create a plan of action to address each deficiency

04

Assign responsibility for each listed deficiency to a specific team member

05

Set deadlines for correcting each deficiency

06

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07

Document all steps taken to fill out deficiencies

08

Schedule a follow-up inspection to ensure all deficiencies have been addressed

Who needs deficiencies were cited?

01

Businesses, organizations, or individuals who have been issued a citation for deficiencies during an inspection

02

Anyone responsible for maintaining compliance with regulations or standards in a specific field

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What is deficiencies were cited?

Deficiencies that were identified during an inspection or audit.

Who is required to file deficiencies were cited?

The organization or individual responsible for addressing the deficiencies.

How to fill out deficiencies were cited?

Deficiencies can be filled out by documenting the issues identified and detailing the corrective actions taken.

What is the purpose of deficiencies were cited?

The purpose is to ensure that deficiencies are addressed and corrected in a timely manner to prevent negative impacts.

What information must be reported on deficiencies were cited?

Information such as the nature of the deficiency, the location where it was identified, and the corrective actions taken.

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