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PRINTED: 07/25/2024 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:ROXBORO ASSISTED LIVING OPCO

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Carefully read the instructions provided with the DHSR MHLCS NC statement form.

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Fill in your personal information accurately, including your name, address, and contact details.

03

Provide detailed information about the services or care you received at the facility.

04

Include the date or dates of the care received.

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Individuals who have received services or care at a DHSR MHLCS NC regulated facility and have concerns or complaints about the care they received.

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What is dhsr mhlcs nc statement?

The DHHS Medical Home Licensure Compliance Supplement North Carolina (dhsr mhlcs nc) statement is a form used to report information related to medical home licensure compliance in North Carolina.

Who is required to file dhsr mhlcs nc statement?

Healthcare facilities operating in North Carolina are required to file the dhsr mhlcs nc statement.

How to fill out dhsr mhlcs nc statement?

The dhsr mhlcs nc statement can be filled out online through the DHHS website or by submitting a hard copy form by mail.

What is the purpose of dhsr mhlcs nc statement?

The purpose of the dhsr mhlcs nc statement is to ensure healthcare facilities in North Carolina are in compliance with medical home licensure requirements.

What information must be reported on dhsr mhlcs nc statement?

The dhsr mhlcs nc statement requires information about the healthcare facility's licensure status, compliance with medical home regulations, and any corrective actions taken.

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