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PRINTED: 03/04/2024 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 and state licensure survey

01

Gather all necessary information and documents required for the survey such as license information, education history, work experience, etc.

02

Carefully read through each question on the survey and provide accurate and honest responses.

03

Double-check all information provided before submitting the survey to ensure accuracy.

04

Follow any specific instructions provided on how to fill out the survey, such as format or supporting documents required.

05

Submit the completed survey within the given deadline to the appropriate licensing authority.

Who needs and state licensure survey?

01

Individuals applying for state licensure in a specific profession or field.

02

Employers or organizations that require employees to hold state licensure in order to practice or work in a certain role.

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What is a state licensure survey?

A state licensure survey is an assessment conducted by state regulatory agencies to evaluate whether healthcare facilities comply with state laws and regulations necessary for licensure.

Who is required to file a state licensure survey?

Healthcare facilities, such as hospitals, nursing homes, and clinics, are required to file a state licensure survey to obtain or maintain their operating licenses.

How to fill out a state licensure survey?

To fill out a state licensure survey, facilities must collect necessary documentation, complete the survey forms accurately, provide required information, and submit the forms by the designated deadline.

What is the purpose of a state licensure survey?

The purpose of a state licensure survey is to ensure that healthcare facilities meet minimum safety and quality standards set by the state to protect public health.

What information must be reported on a state licensure survey?

Facilities must report information regarding their facility operations, patient care practices, staff qualifications, maintenance of safety standards, and compliance with relevant state regulations.

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