Form Cms-2567b - Post-Certification Revisit Report
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-xxxx
POST-CERTIFICATION REVISIT REPORT
PROVIDER/SUPPLIER/CLIA/IDENTIFICATION NUMBER
MULTIPLE CONSTRUCTION
DATE OF REVISIT
A. Building __________________
B. Wing
__________________
Y1
Y2
Y3
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement
Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan
of Correction, that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully
identified using either the regulation or LSC provision number and the identification prefix code previously shown on the
CMS-2567 (prefix codes shown to the left of each requirement on the survey report form).
ITEM
DATE
ITEM
DATE
ITEM
DATE
Y4
Y5
Y4
Y5
Y4
Y5
ID Prefix__________
Correction
ID Prefix__________
Correction
ID Prefix__________
Correction
Reg. # ____________
Completed
Reg. # ____________
Completed
Reg. # ____________
Completed
LSC ______________
____/____/____
LSC ______________
____/____/____
LSC ______________
____/____/____
ID Prefix__________
Correction
ID Prefix__________
Correction
ID Prefix__________
Correction
Reg. # ____________
Completed
Reg. # ____________
Completed
Reg. # ____________
Completed
LSC ______________
____/____/____
LSC ______________
____/____/____
LSC ______________
____/____/____
ID Prefix__________
Correction
ID Prefix__________
Correction
ID Prefix__________
Correction
Reg. # ____________
Completed
Reg. # ____________
Completed
Reg. # ____________
Completed
LSC ______________
____/____/____
LSC ______________
____/____/____
LSC ______________
____/____/____
ID Prefix__________
Correction
ID Prefix__________
Correction
ID Prefix__________
Correction
Reg. # ____________
Completed
Reg. # ____________
Completed
Reg. # ____________
Completed
LSC ______________
____/____/____
LSC ______________
____/____/____
LSC ______________
____/____/____
ID Prefix__________
Correction
ID Prefix__________
Correction
ID Prefix__________
Correction
Reg. # ____________
Completed
Reg. # ____________
Completed
Reg. # ____________
Completed
LSC ______________
____/____/____
LSC ______________
____/____/____
LSC ______________
____/____/____
REVIEWED BY
REVIEWED BY
DATE
SIGNATURE OF SURVEYOR
DATE
I
I
STATE AGENCY I I
(INITIALS)
REVIEWED BY
REVIEWED BY
DATE
TITLE
I
I
I I
CMS RO
(INITIALS)
I
I CHECK () FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
I I
FOLLOWUP TO SURVEY COMPLETED ON
I
I YES
I
I NO
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACULTY? I I
I I
Form CMS-2567B (09/92) EF (11/06)
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