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This document details findings from an unannounced survey conducted on September 8-11, 2024, at Hendersonville Health and Rehabilitation, focusing on deficiencies in medication administration and
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01
Identify the specific regulations or standards that have been violated.
02
Gather evidence and documentation that supports the deficiencies noted.
03
Clearly outline each deficiency, specifying the exact nature of the issue.
04
Provide a detailed explanation for each deficiency, including the impact on compliance and patient safety.
05
List corrective actions that have been taken or will be taken to address the deficiencies.
06
Ensure the statement is organized logically, following the order of the identified deficiencies.
07
Review the statement for clarity, accuracy, and completeness before submission.

Who needs statement of deficiencies and?

01
Healthcare facilities undergoing inspections or audits.
02
Regulatory agencies that evaluate compliance with healthcare regulations.
03
Accrediting organizations that require documentation of deficiencies.
04
Legal professionals involved in healthcare compliance cases.
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A statement of deficiencies is a document that outlines areas where an organization, particularly healthcare facilities, fails to comply with regulatory standards or requirements.
Typically, healthcare providers such as hospitals, nursing homes, and assisted living facilities are required to file a statement of deficiencies following an inspection that identifies non-compliance.
To fill out a statement of deficiencies, organizations must review the findings from regulatory inspections, document specific areas of non-compliance, provide a plan of correction, and submit it to the relevant authorities.
The purpose of a statement of deficiencies is to formally communicate areas of non-compliance to the facility, facilitate corrective actions, and ensure ongoing compliance with healthcare regulations.
The statement must report detailed descriptions of the deficiencies found, references to the applicable regulatory standards, and the facility's plan to address each deficiency.
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