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This document outlines the findings of deficiencies identified during an unannounced follow-up survey conducted at Universal Health Care / Brunswick. It includes details of specific deficiencies related to resident care, such as inadequate hot water temperature in shower rooms, improper documentation of falls, and failure to notify families of COVID-19 cases. A plan of correction is also provided for each deficiency.
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01
Review the necessary regulations and guidelines that apply to your facility.
02
Gather all relevant data and documentation that pertain to the deficiencies.
03
Clearly identify each deficiency by specifying the area and reason for the deficiency.
04
Use specific examples and evidence to support each deficiency listed.
05
Ensure that each deficiency is explained in a concise and straightforward manner.
06
Add recommendations for corrections or improvements for each deficiency.
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Include a timeline for when corrections will be made.
08
Proofread the statement for clarity and accuracy before submission.

Who needs statement of deficiencies and?

01
Healthcare facilities undergoing inspections or audits.
02
Regulatory agencies that assess compliance.
03
Quality assurance teams within healthcare organizations.
04
Accrediting bodies that evaluate facility standards.
05
Administrative staff responsible for maintaining compliance records.
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A statement of deficiencies is a formal document that outlines any issues or non-compliance found during an inspection or review, typically related to healthcare facilities, education institutions, or regulatory compliance.
Entities such as healthcare facilities, educational institutions, or any organization under regulatory oversight that has been found to have deficiencies during an inspection are required to file a statement of deficiencies.
To fill out a statement of deficiencies, organizations should carefully document each deficiency identified, provide evidence of compliance efforts, outline corrective actions taken or planned, and follow any specific formatting or submission guidelines provided by the regulatory authority.
The purpose of the statement of deficiencies is to officially communicate non-compliance findings to the organization, ensure accountability, and provide a framework for corrective action to improve compliance.
The statement of deficiencies must typically report the nature of each deficiency, the regulatory standard that was violated, evidentiary support for the finding, and the corrective actions that will be implemented by the organization.
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