II. Discrepancy Information
Please complete items 1 through 4 below in detail.
1. Description of Discrepancy:
2. Description of How the Discrepancy was Identified:
3. Description of the Corrective Action to Fix the Discrepancy, Including Estimated Time for Implementation:
4. Additional Information that would be Helpful that has not been Included Above:
III. List of Hospice(s) Applicable to this Discrepancy
A hospice may be added more than once if there are multiple time frames for the hospice. It is important that the effects of the Discrepancy Report are quantified; however, "unknown" will be accepted as a valid response.
||Hospice Contact Name
||Hospice Contact Email
||Avg. Eligible Decedents/Caregivers month
||Avg. surveys month