Statement of Deficiencies and Plan of Correction (CMS-2567)

OMB 0938-0391

OMB 0938-0391

This Paperwork package provides information regarding the form used by the Medicare, Medicaid, and the Clinical Laboratory Improvement Amendments (CLIA) programs to document a health care facility's compliance or noncompliance (deficiencies) with regard to the Medicare/Medicaid Conditions of Participation and Coverage, the requirements for participation for Skilled Nursing Facilities and Nursing Facilities, and for certification under CLIA. 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.

All Historical Document Collections
Revision of a currently approved collection 2021-07-13
Approved without change
Reinstatement without change of a previously approved collection 2019-12-12
Approved without change
Extension without change of a currently approved collection 2015-11-30
Approved with change
Extension without change of a currently approved collection 2012-09-25
Approved without change
Reinstatement without change of a previously approved collection 2009-08-10
Approved without change
Extension without change of a currently approved collection 2005-12-30
Approved without change
Reinstatement without change of a previously approved collection 2002-12-04
Approved without change
Extension without change of a currently approved collection 1999-09-02
Approved without change
Extension without change of a currently approved collection 1998-08-11
Approved without change
Extension without change of a currently approved collection 1996-08-27
Approved without change
Revision of a currently approved collection 1996-05-30
Approved without change
Reinstatement without change of a previously approved collection 1994-11-01
Approved without change
Reinstatement with change of a previously approved collection 1992-07-06
Approved without change
Revision of a currently approved collection 1987-10-28
Approved without change
New collection (Request for a new OMB Control Number) 1984-09-14

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