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Medicare-Medicaid Hospital Swing-Bed Survey 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: Medicare-Medicaid Hospital Swing-Bed Survey Report, CMS-1537C, Official Federal Forms Centers For Medicare And Medicaid Services,
COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESCalendar No.MEDICARE/MEDICAID HOSPITAL SWING-BED SURVEY REPORTJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)FACILITY NAME AND ADDRESS (City, State, Zip Code) PROVIDER NUMBERVENDOR NUMBERSURVEY DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .TYPE OF SURVEYTHE PEOPLE OF THE STATE OF NEW YORK TOInitial Approval Reverification ComplaintNUMBER OF BEDS (Check One) 49 or fewer beds 50 59 bedsGREETINGS:SURVEYORS' NAMESTITLESWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,SURVEY TEAM COMPOSITIONIndicate the Number of Surveyors According to Discipline:(Attorney must sign above and type name below)Life Safety Code SpecialistH.A.AdministratorLaboratorianI.B.NurseSanitarianJ.C.DietitianAttorney(s) forTherapistK.D.PharmacistPhysicianL.E.Records AdministratorPsychologistM.F.Social WorkerOtherN.G.Qualified Mental Retardation ProfessionalOffice and P.O. AddressNote: More than one discipline may be marked for surveyors qualified in multiple discilines.Indicate the Total Number of Surveyors Onsite: Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:CMS-1537C (1-92)Page 1American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.MEDICARE/MEDICAID HOSPITAL SWING-BED DIFICIENCIES REPORT1Page of JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)NAME OF FACILITY:DEFICIENCIES2.COMMENTS 3. 1.CoP/STND No.Data Tag No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:CMS-1537C (1-92)Page 2American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.DEFICIENCIESCalendar No.2.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)COMMENTS 3. 1.CoP/STND No.Data Tag No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:CMS-1537C (1-92)Page 3American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.MEDICARE/MEDICAID HOSPITALCalendar No.SWING-BED DEFICIENCIES REPORT INSTRUCTIONSJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Evaluate each of the discrete requirements identified in the Hospital Swing-Bed Interpretive Guidelines (Appendix to the SOM). For each identified deficiency:A. In the first column, identify the data tag number.B. In the second column, write the regulatory citation. If it is a Condition of Participation, enter CoP belowthe regulatory citation.C. In column three, describe the findings and evidence under Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D. Draw horizontal lines to separate identified tag numbers.E. If more space is needed, photocopy FIRST page (front and back).THE PEOPLE OF THE STATE OF NEW YORK TOF. Each surveyor must sign the certifying statement on the last page.G. If there are more surveyors to sign the last page, than are lines available on whichto sign, photocopy the last page and add the additional signatures.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour 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., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.
