Facility Extension Request & Progress Updates
AO:Choose an item.CCN:Click here to enter text.Facility Type:Choose an item.
AOID: Click here to enter text.RO:Choose an item.State:Choose an item.
Name of Facility: Click here to enter text.
Survey End Date:Click here to enter a date. Deficiency Report Sent to Facility: Click here to enter a date.
Ligature / Self Harm Deficiency Cited?Choose an item.IJ Called?Choose an item.
Describe Deficiency: Click here to enter text.
Describe Mitigation Plan: Click here to enter text.
Reason for Extension Request & Description of Hardship: Click here to enter text.
Expected Date of Completion: Click here to enter a date.
Does the AO/SA Recommend CMS Approval of the Extension Request? Choose an item.
** Please attach copies of the deficiency report and facility plan of correction.
FOR CMS USE ONLY:
Extension Granted: Choose an item.Length of Extension:Click here to enter text.
New Expected Date of Completion: Click here to enter a date.Progress Report # 1 Due:Click here to enter a date.
CMS Comments / Notes: Click here to enter text.
Revised: 09.07.2017
Facility Extension Request & Progress Updates
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Date of Progress Report:Click here to enter a date.
Monitoring & Evaluation of Mitigation Plan Effectiveness: Click here to enter text.
Mitigation Plan & Implementation of Approved Necessary Revisions: Click here to enter text.
AO Comments & Additional Information:Click here to enter text.
CMS Comments / Notes:Click here to enter text.
Revised: 09.07.2017