Form CMS-2567, Statement of Deficiencies Instructions
This form contains 26 fields organized into 8 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Continuation Sheet Page Numbering | ||
| Text | ||
| Text | ||
| Continuation Sheet Page Number | Text |
Enter the current continuation sheet page number for this page.
|
| Total Continuation Sheet Pages | Text |
Enter the total number of continuation sheet pages in this set.
|
| Deficiencies and Plan of Correction (First Row) | ||
| Deficiency ID Prefix/Tag | Text |
Enter the deficiency identifier prefix and tag associated with this deficiency entry.
|
| Summary Statement of Deficiencies | Text |
Provide the written summary statement describing the deficiency, including the full regulatory or LSC identifying information.
|
| Plan of Correction | Text |
Describe the corrective actions that will be taken to address the cited deficiency, cross-referenced to the appropriate deficiency as needed.
|
| Completion Date | Date |
Enter the date by which the plan of correction will be completed.
|
| First Deficiency Entry | ||
| Deficiency ID Prefix Tag | Text |
Enter the deficiency’s ID prefix tag (X4) associated with this deficiency citation.
|
| Summary Statement of Deficiencies | Text |
Enter the full summary statement describing the deficiency, including the applicable regulation or LSC identifying information.
|
| Plan of Correction ID Prefix Tag | Text |
Enter the ID prefix tag that links the plan of correction to the corresponding deficiency.
|
| Plan of Correction | Text |
Enter the corrective actions that will be taken to address the cited deficiency and cross-reference them to the appropriate deficiency.
|
| Completion Date | Date |
Enter the date by which the plan of correction will be fully completed (X5).
|
| General | ||
| Deficiency ID Prefix/Tag | Text |
Enter the deficiency identifier prefix or tag corresponding to the deficiency being cited in this row.
|
| Signature | ||
| Multiple Construction Details | ||
| Building | Text |
Enter the building identifier or name for the location referenced in this report.
|
| Wing | Text |
Enter the wing identifier or name within the building referenced in this report.
|
| Provider and Survey Information | ||
| Provider/Supplier/CLIA Identification Number | Text |
Enter the provider, supplier, or CLIA identification number for the facility.
|
| Date Survey Completed | Date |
Enter the date the survey was completed.
|
| Text | ||
| Facility Address | Text |
Enter the facility’s full address including street, city, state, and ZIP code.
|
| Accrediting Organization Performing Survey | Text |
Enter the name of the accrediting organization that performed the survey, if applicable.
|
| Name of Facility Surveyed | Text |
Enter the full name of the facility that was surveyed.
|
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (CMS-2567) (continued) | ||
| Representative Title | Text |
Enter the job title of the laboratory director or provider/supplier representative signing this form.
|
| Signature Date | Date |
Enter the date on which the laboratory director or provider/supplier representative signed this form.
|
| Survey Completion Date | ||
| Date Survey Completed | Date |
Enter the date on which the survey was completed.
|