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PRINTED: 03/08/2017
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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How to fill out this visit was for
How to fill out this visit was for
01
Bring all necessary documents such as ID, insurance information, and medical history.
02
Arrive on time for your appointment.
03
Check in at the front desk and provide your information to the receptionist.
04
Follow the instructions given by the medical staff during your visit.
05
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Who needs this visit was for?
01
This visit is for anyone who needs medical attention, consultation, or treatment from healthcare professionals.
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What is this visit was for?
This visit was for a routine inspection.
Who is required to file this visit was for?
The facility manager is required to file this visit.
How to fill out this visit was for?
To fill out this visit, please provide detailed information about the findings during the inspection.
What is the purpose of this visit was for?
The purpose of this visit is to ensure compliance with safety regulations and standards.
What information must be reported on this visit was for?
All findings, corrective actions taken, and recommendations must be reported on this visit.
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