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PRINTED: 08/29/2023 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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This form is for reporting information related to a specific department within an organization.
All employees within the department are required to file this form.
The form should be filled out with accurate and up-to-date information pertaining to the department.
The purpose of this form is to gather data on the operations and activities of the department for record-keeping and analysis purposes.
Information such as budget allocation, staff members, projects, and performance metrics must be reported on this form.
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