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 Date Remediation Community Describe deficiency Describe remediation plan and timeline Completed Integration 1.1 1.2 Standard 2 Date Remediation Respect/Rights/ Describe deficiency Describe remediation plan and timeline Completed Choice 2.1 2.2
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 Community Integration Describe deficiency Describe remediation plan and timeline Date Remediation Completed 1.1 1.2 Standard 2 Respect/Rights/ Choice Describe deficiency Describe remediation plan and timeline Date Remediation Completed 2.1 2.2