Fill out Form CMS-2567, Statement of Deficiencies with Instafill.ai

The Name and Address of Facility section should include the name of the healthcare facility, its mailing address, and the contact information for the person responsible for submitting the form. This information is essential for CMS to properly identify and communicate with the facility regarding any deficiencies and the required corrective actions.

The Prefix Identification Tag is a unique identifier assigned to each deficiency identified during the survey or inspection. This tag is used to cross-reference the deficiencies listed in the Summary Statement of Deficiencies and the Plan of Correction sections. Properly using the prefix identification tags ensures that all deficiencies are addressed and corrected in the correct order.

Each deficiency should be identified clearly and specifically in the Summary Statement of Deficiencies section. This includes providing a brief description of the deficiency, the applicable regulations or standards that have been violated, and the date the deficiency was identified. Properly documenting each deficiency ensures that all parties involved have a clear understanding of the issues that need to be addressed.

The Plan of Correction section should outline the specific actions the facility will take to address each deficiency identified in the Summary Statement of Deficiencies section. This may include implementing new policies or procedures, providing additional staff training, or making physical improvements to the facility. The plan should also include a timeline for completing each corrective action and the person responsible for ensuring that it is completed.

The Centers for Medicare & Medicaid Services (CMS) may grant waivers for certain deficiencies identified during inspections of hospitals. These waivers are granted based on the severity of the deficiency and its impact on patient care and safety. Hospitals may request a waiver by submitting a Statement of Deficiencies and Plan of Correction (CMS-2567) form. The CMS will review the request and make a determination based on the information provided. It is important to note that not all deficiencies will result in a waiver, and the hospital will be required to correct any identified deficiencies that do not qualify for a waiver.

The asterisk (*) in the form indicates that a deficiency has been identified that may be eligible for a waiver. The hospital must address all deficiencies, whether waivable or not, in the Plan of Correction section of the form. If a waiver is granted, the hospital will still be required to implement a corrective action plan to address the deficiency, but the waiver may allow for a longer timeframe to complete the correction.

The Statement of Deficiencies and Plan of Correction (CMS-2567) form should be signed and dated by the hospital's Administrator or designee. The form should be returned to the CMS as soon as possible, but no later than 30 days from the date of the inspection report. If additional time is needed to complete the correction, the hospital may request an extension by submitting a request in writing to the CMS.

The estimated time required to complete the information collection for the CMS-2567 form varies depending on the number and complexity of the deficiencies identified. The form instructions provide an estimated timeframe for completing each section of the form. However, if there are comments concerning the accuracy of the time estimate or suggestions for improving the form, the hospital should submit these comments to the CMS for consideration.

If there are comments concerning the accuracy of the time estimate or suggestions for improving the CMS-2567 form, the hospital should submit these comments in writing to the CMS. The CMS will review the comments and make any necessary revisions to the form instructions or timeframes. The hospital should continue to work on completing the form as accurately and thoroughly as possible, while also communicating with the CMS if any additional information or clarification is needed.

The following should not be sent to the PRA Reports Clearance Office: completed CMS-2567 forms without accompanying deficiencies or corrections. These forms will be returned to the sender.

Questions or concerns regarding the submission of documents should be directed to the CMS National Training Center at 1-800-638-6922 or by email at [email protected].

The valid OMB control number for the CMS-2567 information collection is 0920-0634.

The expiration date of the OMB approval for the CMS-2567 form is December 31, 2023.

A deficiency is a failure to meet a requirement of the Conditions of Participation (CoPs) or other federal regulations. A recommended waiver is a request for an exception to a specific CoP or regulation due to unusual or extenuating circumstances. The CMS-2567 form is used to report both deficiencies and recommended waivers.

If a facility fails to provide a plan of correction for cited deficiencies, the Centers for Medicare & Medicaid Services (CMS) may take enforcement action. This could include denial of payment for new admissions, termination of the provider agreement, or imposition of a civil money penalty. It is important for facilities to address deficiencies in a timely manner to avoid these consequences.

For nursing homes, CMS is required to make findings available to the public within 60 days of completion of a survey. Plans of correction must be submitted within 30 days of the survey and must be implemented within a reasonable timeframe. For other types of facilities, the timeline may vary, so it is important to refer to the specific regulations or guidance from CMS.

The CMS Regional Office plays a role in the waiver process for facilities seeking relief from certain Medicare Conditions of Participation. The Regional Office reviews and makes recommendations on waiver requests, which are then forwarded to the National Level for a final decision. The Regional Office may also provide guidance and support to facilities during the waiver application process.

The Instructions section of the CMS-2567 form provides guidance on how to complete the form accurately and completely. It includes information on what information is required, how to format the information, and any special instructions or considerations. It is important to read and follow the instructions carefully to ensure that the form is submitted correctly and that any deficiencies or plans of correction are addressed effectively.