Check out this sample revision request form
Check out this sample revision request form
When home care agencies challenge a Type I recommendation after a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, they must complete a revision request form.
Here’s a sample form as filled out by Kosciusko Community Hospital in Warsaw, IN:
Joint Commission Revision Request Form
Organization: Kosciusko Community Hospital
2101 E. DuBois Drive
Warsaw, Indiana 46580
Identification #: 7230
Please be aware that a revision request of any portion of the attached report must be submitted within 30 days of the date of receipt of the report. Please attach this form to your revision request material and forward to:
Report Receiving Center, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181; Attention: Revision Request Personnel.
In order to process your organization’s revision request, please identify which specific standard(s) your organization is requesting to be reviewed.
__ Check here if request is not related to standard scores (please attach details of request)
Recommendations:
• Type I — Written Progress Report — 6 month (Home Care Program — Aug. 3, 1998, Initial Full Survey) Home Health and/or Personal Care/Support
X IC.2
Hospice Services
X IC.2
• Supplemental Recommendations (Home Care Program — Aug. 3, 1998, Initial Full Survey) Home Health and/or Personal Care/Support
__ CC.4.2
__ IM.9.20
__ IM.9.25.1
__ LD.7
__ PE.2.5
__ PF.4
__ PF.4.2
Hospice Services
__ CC.4.2
__ IM.9.
__ LD.7
__ PE.2.5
__ PF.4
__ PF.4.2
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