Get Statement Of Deficiencies Citation Summary Sheet Printed: 10/18/2011 For: Patient Care Associates (

This guide provides users with a clear, step-by-step approach to filling out the Statement of Deficiencies Citation Summary Sheet for Patient Care Associates. Whether you are familiar with legal documents or not, these instructions will help you navigate the form with confidence.

Follow the steps to effectively complete the form.

1. Start by accessing the document. Click the ‘Get Form’ button to retrieve the Statement Of Deficiencies Citation Summary Sheet and open it for editing.
2. Fill out the provider's identification number in the designated field (X1). Ensure that the number is accurate to avoid any issues.
3. Indicate multiple constructions if applicable by completing both the building (X2A) and wing (X2B) sections.
4. Enter the name of the provider or supplier (X3) accurately. In this case, it is Patient Care Associates.
5. Document the date when the survey was completed (X3). Ensure this date reflects the actual date of your evaluation.
6. In the street address, city, state, and zip code section, provide the complete and correct address of the facility (500 Grand Avenue, Englewood, NJ 07631).
7. Proceed to the summary statement of deficiencies section. Clearly state each deficiency with full regulatory or LSC identifying information and cross-reference them with the provider’s plan of correction.
8. Complete the ID prefix and tag fields accordingly for each deficiency noted, ensuring that you maintain accurate records throughout the form.
9. Once the form is filled out, review it for any errors or omissions. Accuracy is crucial in legal documents.
10. Finally, save your changes, and choose to download, print, or share the completed form as required for your records.

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