. ..................... DEPARTMENT.OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES Defendant(s) : .............................. (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _______________ B. WING ___________________ FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN THE STATE OF NEW THE PEOPLE OFOF CORRECTION YORK NAME OF FACILITY (X3) DATE SURVEY COMPLETED TO STREET ADDRESS, CITY, STATE, ZIP CODE ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERRED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG GREETINGS: SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 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 Office and P.O. Address 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 Telephone date for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following theNo.: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. Facsimile No.: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE E-Mail Address: (X6) DATE If continuation sheet Page _____ of _____ Mobile Tel. No.: FORM CMS-2567 (02/99) Previous Versions Obsolete American LegalNet, Inc. www.USCourtForms.com Defendant(s) : ...................................................... INSTRUCTIONS FOR COMPLETION OF THE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (CMS-2567) I. PURPOSE Waivers ­ Waivers of other than Life Safety Code deficiencies in hospitals are by regulations specifically restricted to the RN waiver as provided in This document contains a listing of deficiencies cited by the surveying State TO section 1861(e)(5) of the Social Security Act. The long term care Agency (SA) or Regional Office (RO) as requiring correction. The regulations provide for waiver of the regulations for nursing, patient room Summary Statement of Deficiencies is based on the surveyors' professional size and number of beds per room. The regulations provide for variance of knowledge and interpretation of Medicare and/or Medicaid or Clinical the number of beds per room for intermediate care facilities for the mentally Laboratory Improvement Amendments requirements. GREETINGS: retarded. Any other deficiency must be covered by an acceptable plan of correction. The waiver principle cannot be invoked in any other area than WE COMMAND YOU, that all business and excuses being laid aside, youspecified by regulation. before and each of you attend FORM COMPLETION THE PEOPLE OF THE STATE OF NEW YORK V. II. the Honorable at the Court , Name and Address of Facility ­ Indicate the name and address of the located at County of facility identified on the official certification record. When surveying multiple VI. in room , on the day of , 20 , at o'clock in the Waiver Asterisk(*) ­ The footnote pertaining to the marking by asterisk of noon, and at any recessed sites under one identification number, identify theas a witnessain this action on the part of the site where deficiency recommended waivers presumes an understanding that the use of waivers or adjourned date, to testify and give evidence exists in the text of the deficiency under the Summary Statement of is specifically restricted to the regulatory items. In any event, when the Deficiencies column. asterisk is used after a deficiency statement, the CMS Regional Office should indicate in the right hand column opposite the deficiency whether or Prefix Identification Tag ­ Each cited deficiency and corrective action not and will make you liable to Your failure to comply with this subpoena is punishable as a contempt of courtthe recommended waiver has been accepted. should be preceded by the prefix identification tag (as shown to the left of the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the regulation in the State Operations Manual or survey report form). For result of your failure to comply. example, a deficiency in Patient Test Management (493.1107) would be VII. Signature ­ This form should be signed and dated by the provider or preceded by the appropriate D-Tag in the 3000 series. A deficiency cited in supplier representative or the laboratory director. The original, with the Witness, provision 2-1 , one offacility's proposed corrective action, must be returned to the appropriate the Justices of the the Life Safety Code Honorable (construction) would be preceded by K8. Place this appropriate identification tagdaythe column labeled ID Prefix Tag. in of surveying agency (SA or RO) within 10 days of receipt. Please maintain a Court in County, , 20 copy for your records. III. Summary Statement of Deficiencies ­ Each cited deficiency should be (Attorney followed by full identifying information, e.g., 493.1107(a). Each Life Safety must sign above and type name below) Code deficiency should be followed by the referenced citation from the Life Safety Code and the provision number shown on the survey report form. Attorney(s) for 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 retur