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This document outlines the findings from a health inspection survey conducted at the Good Samaritan Home & Rehabilitative Center, detailing any deficiencies and the corresponding plans for correction. The facility was found to be in compliance with the relevant regulations during the investigation of complaint IN00439469.

How to fill out cms-2567

How to fill out cms-2567

1. Obtain the CMS-2567 form, typically available from the CMS or state survey agency website.
2. Fill out the identification section with the facility's name, address, and provider number.
3. Include the date of the survey and the name of the inspector.
4. Document each deficiency found during the inspection in the appropriate sections, including regulatory citations.
5. Provide a detailed description of each deficiency, including the potential impact on residents or patients.
6. Insert the plan of correction for each deficiency if applicable.
7. Review the completed form for accuracy and comprehensiveness.
8. Submit the CMS-2567 form to the appropriate state agency or regional CMS office.

Who needs cms-2567?

1. Healthcare facilities that are surveyed by CMS or state survey agencies.
2. Nursing homes and long-term care facilities that are required to comply with federal regulations.
3. Any facility seeking certification or recertification for Medicare or Medicaid services.

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What is cms-2567?

CMS-2567 is a form used by health care facilities to report deficiencies identified during surveys conducted by the Centers for Medicare & Medicaid Services (CMS) or its authorized agents.

Who is required to file cms-2567?

Health care facilities that participate in Medicare and Medicaid programs and are subject to CMS surveys are required to file CMS-2567.

How to fill out cms-2567?

To fill out CMS-2567, facilities must provide detailed information about the deficiencies identified, including the nature of the deficiencies, the date they were identified, and a plan for correction, along with a signature from the responsible official.

What is the purpose of cms-2567?

The purpose of CMS-2567 is to formally document compliance issues in health care facilities, facilitate a plan of correction, and ensure that facilities take necessary actions to rectify deficiencies to maintain their participation in federal health care programs.

What information must be reported on cms-2567?

CMS-2567 must report the specific deficiencies found during the survey, the regulatory requirements that were violated, any corrective actions taken, and the responsible party's information.