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This document outlines the deficiencies identified during the 2017 survey at Northwest Regional Surgery Center, including infection control failings and governing body meeting frequency.
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01
Review the regulations and guidelines provided by the relevant governing body.
02
Identify areas that are not in compliance with the regulations or guidelines.
03
Document specific details of the deficiencies, including dates, observations, and any supporting evidence.
04
Develop a plan of correction to address each deficiency identified.
05
Submit the completed statement of deficiencies to the appropriate authorities for review and approval.

Who needs statement of deficiencies and?

01
Healthcare facilities such as hospitals, nursing homes, and clinics.
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Regulatory agencies responsible for overseeing and monitoring compliance with healthcare regulations.
03
Insurers or accrediting bodies that require evidence of compliance with regulations.
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The statement of deficiencies is a document that outlines specific areas in which a facility or organization fails to meet regulatory standards or requirements.
Organizations or facilities that have been found to be non-compliant with regulatory standards are required to file a statement of deficiencies.
To fill out a statement of deficiencies, an organization must provide detailed information about the deficiencies identified, including specific regulations breached and corrective action plans.
The purpose of the statement of deficiencies is to formally acknowledge non-compliance and outline steps for remediation to ensure adherence to regulatory standards.
The statement of deficiencies must report the nature of the deficiencies, the specific regulations violated, and a plan for corrective action including timelines for completion.
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