Hospice Survey And Deficiencies Report
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Hospice Survey And Deficiencies Report Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Hospice Survey And Deficiencies Report, CMS-643, Official Federal Forms Centers For Medicare And Medicaid Services,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..... ... ..
DEPARTMENT. OF HEALTH AND HUMAN SERVICES
:
CENTERS FOR MEDICARE & MEDICAID SERVICES
Index No.
Form Approved
OMB No. 0938-0379
:
Calendar No.
Hospice Survey and Deficiencies Report
Plaintiff(s)
Provider Number
1.
2.
3.
Name of Facility
-against-
Page ____
JUDICIAL SUBPOENA of ____
Survey Date
:
Was this hospice surveyed for compliance with 42 CFR 418.100?
I Yes
:
I No
:
L50
:
If this hospice provides inpatient care directly, is theDefendant(s) provided on the premises?
inpatient care
:
L51
Has a waiver of core nursing services been granted?
L53
..
.. .
I. .Yes. . . . . . . . I. .No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
L52 4. If "Yes" indicate date
I
THE PEOPLE OF No STATE OF NEW YORK
THE
Yes
5.
6.
TO
Indicate type of setting(s) in which the hospice provides routine home care.
L54
Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care
GREETINGS:
from the hospice.
L55
I Private residence I SNF
I NF
I Other (specify)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Court
L56 ,
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify andsurvey.
give evidence as a witness in this action on the part of the
8. Number of records reviewed during
L57
7.
Number of hospice patients admitted during recent 12 month the
the Honorable
at period.
9.
Number of home visits conducted to patients in a private residence.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
L58
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
10. Number of home visits conducted to patients in residential facilities.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
11. Does this hospice operate under the same provider number at
more than one location?
I Yes
I No
Surveyor Signature
L60 12. If "Yes" enter
number of locations.
L61
(Attorney must sign above and type name below)
13. Does this hospice operate as part of another entity that participates
in the Medicare program?
I Yes
L59
I No
L62 14. If "Yes" enter the Medicare provider
number of the entity.
L63
Attorney(s) for
Title
Date
Office and P.O. Address
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 0938-0379. The time required to complete this information collection is estimated to average 2.5
hours 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Mailstop N2-14-26,
Telephone No.:
7500 Security Boulevard, Baltimore, Maryland 21244-1850.
CMS-643 (11-94)
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar No.
Hospice Survey and Deficiencies Report
Plaintiff(s)
Deficiencies
-against-
:
Page ____
JUDICIAL SUBPOENA of ____
:
:
Data Tag Number
CoP/Stnd. No.
Comments
:
Defendant(s)
:
......................................................
THE PEOPLE OF THE STATE OF NEW YORK
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on this
form the facility was found to be in compliance with the standards and/or the and P.O. Address
Office Conditions of Participation.
Surveyor Signature
Surveyor Signature
CMS-643 (11-94)
Title
Title
Date
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Date
American LegalNet, Inc.
www.USCourtForms.com