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This document outlines the deficiencies found during the survey of Signature Healthcare of Terre Haute and includes the plan of correction. It summarizes the investigation of complaints and states compliance with regulations.
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How to fill out form cms-2567
How to fill out form cms-2567
01
Obtain a copy of the CMS-2567 form.
02
Enter the date of the survey in the designated section.
03
Fill in the facility’s name and address accurately.
04
Provide the provider number and the state survey agency’s name.
05
Describe the regulatory requirements being violated in detail.
06
Include specific findings and observations that support the violation claims.
07
Note any immediate harm or potential harm to residents or patients.
08
Attach any documents or evidence that support the findings.
09
Review the filled form for accuracy and completeness.
10
Sign and date the form before submission.
Who needs form cms-2567?
01
Healthcare facilities undergoing surveys from the Centers for Medicare & Medicaid Services (CMS).
02
Providers seeking to document violations or deficiencies in their facility.
03
Inspectors or compliance officers conducting evaluations of healthcare facilities.
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What is form cms-2567?
Form CMS-2567 is a document used by the Centers for Medicare & Medicaid Services (CMS) to record survey findings for healthcare facilities.
Who is required to file form cms-2567?
Healthcare facilities that are participating in Medicare or Medicaid programs are required to file Form CMS-2567.
How to fill out form cms-2567?
To fill out Form CMS-2567, you must provide the facility's information, detailed survey findings, and any necessary corrections or updates based on the survey results.
What is the purpose of form cms-2567?
The purpose of Form CMS-2567 is to provide a comprehensive report of deficiencies identified during the survey of healthcare facilities and to ensure compliance with safety and quality standards.
What information must be reported on form cms-2567?
Form CMS-2567 must report facility identification details, surveyor findings, specific deficiencies, and any corrective actions taken or proposed.
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