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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/CLIAAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15502902/10/2016FORM
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01
Access the licensure survey form online or obtain a physical copy from the licensing authority.
02
Read the instructions and requirements carefully to ensure you understand what information is needed.
03
Begin by providing your personal details such as name, address, contact information, and any relevant identification numbers.
04
Provide information about your educational background, including the degrees or certifications obtained.
05
Indicate your professional experience by listing any relevant employment history, specifying the organization, position held, and duration of employment.
06
Answer all the questions on the survey truthfully and accurately, providing any necessary supporting documentation if required.
07
If applicable, disclose any disciplinary actions or legal issues related to your professional practice.
08
Review all the information provided to ensure it is complete and correct.
09
Submit the completed licensure survey form through the designated submission method, whether online or by mail.
10
If submitting online, make sure to follow any additional instructions for attaching or uploading supporting documents.
11
Keep a copy of the completed survey and any supporting documents for your records.

Who needs licensure survey completed on?

01
Anyone who is required to obtain a professional license or certification in a specific field needs to complete a licensure survey.
02
This may include but is not limited to individuals seeking licensure in industries such as healthcare, education, law, engineering, or real estate.
03
The licensing authority or regulatory body responsible for granting the professional license usually requires the completion of a licensure survey as part of the application process.
04
Additionally, individuals who already possess a professional license may be required to periodically complete a licensure survey as part of their license renewal process.
05
The specific requirements vary depending on the jurisdiction and the nature of the profession or occupation.
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Licensure survey is completed on the compliance and operational standards set forth by licensing authorities for healthcare facilities, ensuring adherence to state and federal regulations.
Healthcare facilities, including hospitals, nursing homes, and assisted living facilities, are required to file the licensure survey.
To fill out the licensure survey, facilities must gather relevant operational data, ensure compliance with all required standards, and complete the prescribed forms accurately and thoroughly.
The purpose of the licensure survey is to assess whether healthcare facilities meet the necessary legal and regulatory standards to operate safely and effectively.
Facilities must report information including staff qualifications, patient care protocols, facility policies, and compliance with safety and health regulations.
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