Fillable Form Cms-2567 - Statement Of Deficiencies And Plan Of Correction printable pdf download

Form Cms-2567 - Statement Of Deficiencies And Plan Of Correction

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0391

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY COMPLETED

STATEMENT OF DEFICIENCIES

IDENTIFICATION NUMBER:

A. BUILDING _______________

AND PLAN OF CORRECTION

B. WING ___________________

NAME OF FACILITY

STREET ADDRESS, CITY, STATE, ZIP CODE

(X5)

(X4) ID

SUMMARY STATEMENT OF DEFICIENCIES

PLAN OF CORRECTION

COMPLETION

PREFIX

(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL

PREFIX

(EACH CORRECTIVE ACTION SHOULD BE

DATE

TAG

REGULATORY OR LSC IDENTIFYING INFORMATION)

TAG

CROSS-REFERRED TO THE APPROPRIATE DEFICIENCY)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the

patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing

homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation

’

LABORATORY DIRECTOR

S OR PROVIDER/SUPPLIER REPRESENTATIVE

S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

If continuation sheet Page _____ of _____