| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 65C0001001 | (X3) Date Survey Completed 02/08/2019 |
| Name of Provider or Supplier Hafa Adai Specialist Group, Llp | Street Address, City, State Sunflower Villa, 280 Pale San Vitores, Tamuning, GU | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| K0000 | 42 CFR 416.44 A direct federal recertification survey was conducted on January 31, 2019, February 1, 2019 and February 8, 2019. The survey was conducted in part, in accordance with 42 Code of Federal Regulations, Part 416.44: Condition for Coverage - Environment. At the survey's conclusion, Hafa Adai Surgical Group was found not to be in compliance with the requirements for coverage in Medicare and Medicaid. Date Built: Before 2009 Construction Type: Type I No. of Stories: 3 Ground Floor is occupied by Hafa Adai Specialty Group First/Second Floor: rental apartments Facility Address: Hafa Adai Specialty Group Sunflowervilla Bldg. 280 Pale San Vitores Rd. Tamuning, GU 96913 |