Form CMS-2567, Statement of Deficiencies Completed Form Examples and Samples
Explore comprehensive examples of Form CMS-2567, showcasing how to report deficiencies in healthcare settings such as nursing homes and hospitals. These samples include detailed deficiency summaries, plans of correction, and completion dates, providing valuable insights for healthcare administrators.
CMS-2567 Example – Nursing Home Deficiency Report
How this form was filled:
This example details a nursing home's deficiencies related to staffing levels. It includes a summary of the deficiencies, the nursing home’s plan of correction, and completion dates. The form records specific violations regarding insufficient staff numbers and details the corrective actions planned.
Information used to fill out the document:
- Facility Name: Green Valley Care Center
- Facility Address: 456 Health Ave, New York, NY
- Survey Date: 03/15/2025
- Deficiency Summary: Insufficient staffing levels during evening shifts
- Plan of Correction: Hire additional evening staff and adjust current staff schedules
- Completion Date: 04/30/2025
- Surveyor's Name: Jane Smith, RN
- Signature: Jane Smith
What this filled form sample shows:
- Deficiency related to staffing levels and related impact
- Plan of correction proposed with clear steps
- Scheduled completion date for corrective actions
- Valid signature and inclusion of surveyor's credentials
Form specifications and details:
| Use Case: | Documenting deficiencies in a nursing home setting related to staffing |
| Form Purpose: | To provide an official report of healthcare facility deficiencies and propose corrective actions. |
CMS-2567 Example – Hospital Infection Control Deficiency Report
How this form was filled:
This example illustrates deficiencies in a hospital's infection control procedures. It includes a summary of the identified issues, the hospital’s plan for correction, and the deadlines for implementation. The focus is on inadequate sterilization processes and outlines the steps the hospital will take to address these issues.
Information used to fill out the document:
- Facility Name: Riverside Medical Center
- Facility Address: 123 Healthcare Blvd, Los Angeles, CA
- Survey Date: 01/10/2025
- Deficiency Summary: Inadequate sterilization procedures in the surgical department
- Plan of Correction: Revise sterilization protocol and retrain staff on infection control measures
- Completion Date: 02/28/2025
- Surveyor's Name: John Doe, RN
- Signature: John Doe
What this filled form sample shows:
- Deficiency focused on infection control and sterilization processes
- Detailed plan of correction with action items
- Clear completion date for implementing corrections
- Official signature with surveyor’s professional details
Form specifications and details:
| Use Case: | Documenting deficiencies in a hospital setting related to infection control |
| Form Purpose: | To officially report and address deficiencies in healthcare facilities with a focus on infection prevention protocols. |
