CMS-2567

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

Agency
CMS
Revision
2022-03-18
Fillable fields
22
Pages
5
Official source
CMS form page
Checked
October 20, 2026
Fill CMS-2567 online
Page 1 of form CMS-2567

Form CMS-2567: Statement of Deficiencies and Plan of Correction

Form CMS-2567 is the Statement of Deficiencies and Plan of Correction from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health & Human Services. Its instructions say it lists deficiencies cited by the surveying State Agency (SA), Accrediting Organization (AO) or Regional Office (RO) as requiring correction, based on the surveyors' professional knowledge and interpretation of Medicare and/or Medicaid or Clinical Laboratory Improvement Amendments requirements.

The first page identifies the provider, supplier or CLIA identification number, the building and wing, the date the survey was completed, the facility and any accrediting organization. Below are two columns side by side: the summary statement of deficiencies and the plan of correction, each keyed to an ID prefix tag, with a completion date. Continuation pages repeat the columns, and a signature page carries notes on disclosure and waivers.

The instructions say the provider or supplier representative or the laboratory director signs and dates the form, and the original goes back to the surveying agency within 10 days of receipt. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Form CMS-2567: Statement of Deficiencies and Plan of Correction, as printed by CMS

What's on Form CMS-2567

Header items X1 to X3

Provider/Supplier/CLIA Identification Number, Multiple Construction with A. Building and B. Wing, and Date Survey Completed.

Facility and accrediting organization

Name of facility surveyed, facility address (street, city, state, ZIP code) and the name of the accrediting organization performing the survey, if applicable.

Summary statement of deficiencies (X4)

An ID prefix tag column and the deficiencies. The form says each deficiency should be preceded by full regulatory or LSC identifying information.

Plan of correction and completion date (X5)

A second ID prefix tag column, the plan of correction and a completion date. The form says each corrective action should be cross-referred to the appropriate deficiency.

Continuation pages

Further pages repeat the facility name, date survey completed and both columns, marked as a continuation sheet with page numbers.

Signature page (X6)

Notes on asterisked deficiencies and disclosure, then the laboratory director's or provider/supplier representative's signature, title and date.

The form has a first page, continuation pages, a signature page, instructions and a PRA disclosure statement.

How Form CMS-2567 is completed

  1. 1

    Name the facility

    Use the name and address on the official certification record. When multiple sites share one identification number, the instructions say to name the site in the text of the deficiency.

  2. 2

    Tag each deficiency

    Put the prefix identification tag from the State Operations Manual or survey report form in the ID Prefix Tag column. The form's examples are a D-Tag in the 3000 series for 493.1107 and K8 for Life Safety Code provision 2-1.

  3. 3

    Write the summary statement

    Follow each cited deficiency with full identifying information, such as 493.1107(a). A Life Safety Code deficiency is followed by its Life Safety Code citation and provision number.

  4. 4

    Write the plan of correction

    State the facility's plan for corrective action and the anticipated time of correction. The instructions say an explicit date must be shown, or the date completed if the action is done.

  5. 5

    Sign and return it

    The provider or supplier representative or laboratory director signs and dates the form. The instructions say the original goes back to the SA, AO or RO within 10 days of receipt, with a copy kept.

These steps follow the form's own instructions.

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Return, disclosure and waivers

Where it goes

The instructions say the original, with the facility's proposed corrective action, goes back to the appropriate surveying agency (SA, AO or RO) within 10 days of receipt, and to keep a copy.

Disclosure

The form says findings are disclosable 90 days after the survey whether or not a plan of correction is provided, except for nursing homes, where findings and plans are disclosable 14 days after they are made available to the facility.

Plan of correction

The form says that if deficiencies are cited, an approved plan of correction is requisite to continued program participation.

Waivers

The instructions say waivers in hospitals other than Life Safety Code are limited to the RN waiver in section 1861(e)(5) of the Social Security Act, and list the long-term care and intermediate care facility cases. Other deficiencies need an acceptable plan of correction.

OMB number and time

OMB No. 0938-0391. The form footer says OMB approval expires 03/31/2025. The PRA statement calls it a mandatory collection and estimates an average of 18 hours per response.

Questions

The form says not to send applications, claims or sensitive documents to the PRA Reports Clearance Office, and gives [email protected] for questions about where to submit documents.

Related forms

Who uses Form CMS-2567?

  • Surveying agencies

    The instructions say the deficiencies are cited by the surveying State Agency (SA), Accrediting Organization (AO) or Regional Office (RO).

  • Providers and suppliers

    The plan of correction column holds the facility's plan for corrective action. The instructions say the provider or supplier representative signs and dates the form.

  • Clinical laboratories

    The header asks for a CLIA identification number, and the signature line is for the laboratory director or a provider or supplier representative.

  • Nursing homes

    The form says findings and plans of correction for nursing homes are disclosable 14 days after the documents are made available to the facility.

  • CMS Regional Office

    When an asterisk follows a deficiency, the instructions say the CMS Regional Office indicates opposite it whether the recommended waiver has been accepted.

The instructions name the parties that cite deficiencies, sign the form and review waivers.

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Questions about Form CMS-2567

What is Form CMS-2567?

It is the Statement of Deficiencies and Plan of Correction. Its instructions say it lists deficiencies cited by the surveying SA, AO or RO as requiring correction.

Who signs Form CMS-2567?

The instructions say the provider or supplier representative or the laboratory director signs and dates it.

How long is there to return Form CMS-2567?

The instructions say the original, with the facility's proposed corrective action, goes back to the surveying agency (SA, AO or RO) within 10 days of receipt.

What goes in the plan of correction?

The facility's plan for corrective action and the anticipated time of correction, with an explicit date, or the date completed if the action is already done. Each action is cross-referred to its deficiency.

When are the findings made public?

The form says findings are disclosable 90 days after the survey, or for nursing homes 14 days after the documents are made available to the facility.

What does an asterisk after a deficiency mean?

The form says it denotes a deficiency the institution may be excused from correcting if it is determined that other safeguards provide sufficient protection to the patients. The CMS Regional Office indicates whether the recommended waiver is accepted.