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PRINTED: 08/10/2021 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION
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01
Read the survey instructions carefully before starting.
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Begin by providing your personal information, including name, contact details, and any relevant identifiers.
03
Describe the nature of your complaint in detail, ensuring to include dates, locations, and any involved parties.
04
Provide any evidence or documentation that supports your complaint, such as emails, photos, or witness statements.
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Answer any specific questions in the survey related to your experience or the complaint process.
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Review your responses to ensure accuracy and completeness.
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Submit the survey according to the provided guidelines, whether electronically or in hard copy.

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Individuals who have experienced an issue or misconduct.
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A complaint investigation survey is a process used to collect information about complaints to determine their validity and to decide on further actions or resolutions.
Individuals or organizations that have received a formal complaint or that are subject to regulatory oversight may be required to file a complaint investigation survey.
To fill out a complaint investigation survey, one should read the instructions carefully, provide accurate details about the complaint, respond to all questions truthfully, and submit by the specified deadline.
The purpose of a complaint investigation survey is to gather detailed information about complaints to assess their validity and to inform decision-making on necessary corrective actions.
The survey typically requires the complainant's details, a description of the complaint, any relevant dates, and any supporting documentation or evidence.
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