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Form CMS-2567

  • Record of survey
  • Document & justifies determination of compliance
  • Aids facility in:
    • Analyzing deficient practices & failures
    • Developing plans of correction

Form CMS-2567 is the record of the survey wherein the survey team documents and justifies its determination of compliance and informs the provider or supplier of its state of compliance with the requirements for participation in Federal programs. This information will serve as the basis for the facility to analyze its deficient practices or system failures and to develop plans of correction. The form may also document deficient practices identified by means other than an onsite survey, such as a review of compliance with the requirements to transmit comprehensive assessments to the State Agency.

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