Get Printed: Mab/2014 Form Approved Omb No. 0938-0391 - Chfs Ky

The surveys take place every 9 to 15 months, with an average of every 12 months. WHY ARE SURVEYS PERFORMED? Surveys are conducted to make sure that the long term care facility is meeting state and federal standards which spell out very specifically how care must be provided to long term care facility residents.

OMB 0938-0391 This form becomes the evidentiary basis for CMS certification decisions (including termination or denial of participation), and the form of public disclosure. The latest form for Statement of Deficiencies and Plan of Correction (CMS-2567) expires 2023-05-31 and can be found here.

The CMS-2567 form comprises two main elements: a statement of deficiencies written by inspectors on behalf of the Centers for Medicare and Medicaid Services (CMS) and a plan of correction written by the hospital. The overall purpose of the form is to document findings of non-compliance with Medicare rules.

This survey evaluates the facility for potential hazards pertaining to fire and life safety hazards. The LSC survey report is issued separate from the health survey report. The Plan of Correction (or POC) is a facility's written response to cited deficiencies; found in the right hand column of the CMS 2567 form.

Form CMS-2567 is the record of the survey wherein the survey team documents and justifies its determination of compliance and informs the provider or supplier of its state of compliance with the requirements for participation in Federal programs.

Plan of Correction – In the column Plan of Correction, the statements should reflect the facility's plan for corrective action and the anticipated time of correction (an explicit date must be shown). If the action has been completed when the form is returned, the plan should indicate the date completed.