Form Cms2567 PDF Details

If you are a small business owner, you may be wondering what Form CMS2567 is and if you need to fill it out. This form is for businesses with employees who work in California. It is used to report information about the workers, such as their wages and hours. Filling out this form can help ensure that your business is in compliance with state laws. If you have any questions about the form or how to complete it, please contact your local labor department. Thank you for your time!

QuestionAnswer
Form NameForm Cms2567
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2567, cms plan of correction template, cms form 2567, cms 2567 plan of correction

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

______________________

(X3) DATE SURVEY

COMPLETED

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY

OR LSC IDENTIFYING INFORMATION)

ID

PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)

COMPLETION

DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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 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.

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

Event ID:

Facility ID:

If continuation sheet Page 1 of 1

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