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EXTENDEDPARTIAL EXTENDED SURVEY WORKSHEET by ffh13833

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									DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
                        EXTENDED/PARTIAL EXTENDED SURVEY WORKSHEET
FACILITY                                                           STANDARD OR ABBREVIATED SURVEY DATES
                                                                           _____/_____/_____ to _____/_____/_____
                                                                            Mo    Day    Yr      Mo    Day   Yr
PROVIDER NO.                                                       EXTENDED/PARTIAL EXTENDED SURVEY DATES
                                                                           _____/_____/_____ to _____/_____/_____
                                                                            Mo    Day    Yr      Mo    Day   Yr

I Extended Survey: Substandard care determined during Standard Survey resulting in Extended Survey.
I Partial Extended Survey: Substandard care determined during Abbreviated Survey resulting in Partial Extended Survey.

Check all requirements not met that resulted in the Extended or Partial Extended Survey.

I 483.13         I 483.15       I 483.25

Document observations from extended/partial extended survey
Tag/Concern




                                                     (continued on back)
Form CMS-673 (07/95)
Document observations from extended/partial extended survey (continued)
Tag/Concern




Form CMS-673 (07/95)

								
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