Statement of Deficiencies Citation Summary Sheet PRINTED: 10/18/2011 For: PATIENT CARE ASSOCIATES ( 23377 / NJ23377 ) Survey Event: NYIB11, Exit Date 08/18/2010 Citations Cited This Visit Regulation Type Regulation ID Regulation Version-2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the Provider/Supplier identification number in the designated field (X1). This is crucial for accurate record-keeping.
  3. Fill in the multiple construction details, including building and wing information (X2). If there are no additional wings, you may leave this blank.
  4. Input the date of survey completion (X3) as indicated on your document. This helps track when the survey was conducted.
  5. Complete the street address, city, state, and zip code fields accurately to ensure proper identification of the facility.
  6. In the summary statement section, list each deficiency along with its regulatory identifying information. Ensure that each deficiency is clearly marked.
  7. For each deficiency noted, provide a corresponding plan of correction. This should be cross-referenced with the appropriate deficiency tag.
  8. Finally, have the laboratory director or provider/supplier representative sign and date at the bottom of the form to validate your entries.

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You may quickly fill out, modify, and even eSign your Statement of Deficiencies Citation Summary Sheet PRINTED: 10/18/2011 For: PATIENT CARE ASSOCIATES ( 23377 / NJ23377 ) Survey Event: NYIB11, Exit Date 08/18/2010 Citations Cited This Visit Regulation Type Regulation ID Regulation Version utilizing DocHub. Create a new profile and begin your free trial. After that, you may upload the file with the form and simply make all the necessary edits. No need to print on paper or use a third-party application to sign it, as you can put your electronic signature on your document quicker via DocHub.

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