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12/29/2022PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION

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Fill out the patient information section with the name, date of birth, and contact information of the person visiting.

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This visit was for individuals who are seeking medical attention or treatment at the specified location.

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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 manager of the facility is required to file this visit.

How to fill out this visit was for?

The visit report must be completed electronically through the online portal.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with regulations and standards.

What information must be reported on this visit was for?

All findings, observations, and any corrective actions taken must be reported.

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