Provider Name: ____________________________ Provider Medicaid ID: _______________________ Facility Address: __________________________ County: __________________________________ Presumptively Date Remediation Describe why setting meets Institutional Describe remediation plan and timeline Completed presumptively institutional setting criteria. Setting Criteria Standard 1 Setting Describe deficiency Describe remediation plan and timeline Date Remediation Completed 1.1 1.2 1.3 1.4 1.5 1.6 Standard 2 Describe deficiency Describe remediation plan and timeline Date Remediation Completed Rooms/Privacy 2.1 2.2 2.3 2.4 2.5 2.6 2.7
Provider Name: ____________________________ Provider Medicaid ID: _______________________ Facility Address: __________________________ County: __________________________________ Presumptively Institutional Setting Criteria Describe why setting meets presumptively institutional setting criteria. Describe remediation plan and timeline Date Remediation Completed Standard 1 Setting Describe deficiency Describe remediation plan and timeline Date Remediation Completed 1.1 1.2 1.3 1.4 1.5 1.6 Standard 2 Rooms/Privacy Describe deficiency Describe remediation plan and timeline Date Remediation Completed 2.1 2.2 2.3 2.4 2.5 2.6 2.7