Form CMS-2567 Statement of Deficiencies and Plan of Correction

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF FACILITY
(X4) ID
PREFIX
TAG

FORM APPROVED

OMB NO. 0938-0391

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY COMPLETED

A. BUILDING _______________
B. WING ___________________

STREET ADDRESS, CITY, STATE, ZIP CODE
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
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
FORM CMS-2567 (02/99) Previous Versions Obsolete

TITLE

(X6) DATE
If continuation sheet Page _____ of _____

INSTRUCTIONS FOR COMPLETION OF THE STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION (CMS-2567)

I.

PURPOSE
This document contains a listing of deficiencies cited by the surveying
State Agency (SA) or Regional Office (RO) as requiring correction. The
Summary Statement of Deficiencies is based on the surveyors’ professional
knowledge and interpretation of Medicare and/or Medicaid or Clinical
Laboratory Improvement Amendments requirements.

II.

FORM COMPLETION
Name and Address of Facility – Indicate the name and address of the
facility identified on the official certification record. When surveying
multiple sites under one identification number, identify the site where
a deficiency exists in the text of the deficiency under the Summary
Statement of Deficiencies column.
Prefix Identification Tag – Each cited deficiency and corrective action
should be preceded by the prefix identification tag (as shown to the left
of the regulation in the State Operations Manual or survey report form).
For example, a deficiency in Patient Test Management (493.1107) would
be preceded by the appropriate D-Tag in the 3000 series. A deficiency
cited in the Life Safety Code provision 2-1 (construction) would be
preceded by K8. Place this appropriate identification tag in the column
labeled ID Prefix Tag.

III.

Summary Statement of Deficiencies – Each cited deficiency should be
followed by full identifying information, e.g., 493.1107(a). Each Life
Safety Code deficiency should be followed by the referenced citation
from the Life Safety Code and the provision number shown on the survey
report form.

IV.

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. The date indicated for completion of the corrective action
must be appropriate to the level of the deficiency(ies).

V.

Waivers – Waivers of other than Life Safety Code deficiencies in hospitals
are by regulations specifically restricted to the RN waiver as provided
in section 1861(e)(5) of the Social Security Act. The long term care
regulations provide for waiver of the regulations for nursing, patient
room size and number of beds per room. The regulations provide for
variance of the number of beds per room for intermediate care facilities
for the mentally retarded. Any other deficiency must be covered by an
acceptable plan of correction. The waiver principle cannot be invoked in
any other area than specified by regulation.

VI. Waiver Asterisk(*) – The footnote pertaining to the marking by asterisk
of recommended waivers presumes an understanding that the use of
waivers is specifically restricted to the regulatory items. In any event,
when the asterisk is used after a deficiency statement, the CMS Regional
Office should indicate in the right hand column opposite the deficiency
whether or not the recommended waiver has been accepted.
VII. Signature – This form should be signed and dated by the provider or
supplier representative or the laboratory director. The original, with the
facility’s proposed corrective action, must be returned to the appropriate
surveying agency (SA or RO) within 10 days of receipt. Please maintain a
copy for your records.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0391 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average [Insert Time (hours or minutes)] per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Division of Acute Care Services at 410-786-8021.