Authorization For State Agency Psychiatric Hospitall Validation Survey {CMS-2802F}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY PSYCHIATRIC HOSPITAL VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF PSYCHIATRIC HOSPITAL CMS CERTIFICATION NUMBER: _______________________________ 3. THIS HOSPITAL IS CURRENTLY DEEMED BY TJC NONE 4. CHECK A OR B; DO NOT CHECK BOTH A. THIS VALIDATION SURVEY IS BASED ON A SAMPLE SELECTION. CHECK 1 OR 2. DO NOT CHECK BOTH. 1. PLEASE CONDUCT A FULL VALIDATION SURVEY FOLLOWING THE PROTOCOLS AND PROCEDURES FOR A MEDICARE CERTIFICATION SURVEY WITHIN 60 CALENDAR DAYS OF _________________________ (ENTER AO NAME) ACCREDITATION SURVEY END DATE. THE SCHEDULED END DATE OF THE ACCREDITATION SURVEY IS: _________________________ IF APPLICABLE, CHECK THE FOLLOWING: THIS IS AN INITIAL ACCREDITATION SURVEY FOR THIS CURRENTLY PARTICIPATING, NON-DEEMED FACILITY. 2. THIS IS A MID-CYCLE VALIDATION SURVEY. PLEASE CONDUCT A FULL VALIDATION SURVEY FOLLOWING THE PROTOCOLS AND PROCEDURES FOR A MEDICARE CERTIFICATION SURVEY SA MUST COMPLETE ALL VALIDATION PACKET DOCUMENTS LISTED IN EXHIBIT 63 FOR ANY FULL VALIDATION SURVEY. B. THIS VALIDATION SURVEY IS BASED ON ALLEGATIONS OF SIGNIFICANT DEFICIENCIES WHICH COULD AFFECT THE HEALTH AND SAFETY OF PATIENTS. CHECK ONE OF THE FOLLOWING: POTENTIAL IJ--INITIATE SURVEY WITHIN 2 WORKING DAYS; OR INITIATE SURVEY WITHIN 45 CALENDAR DAYS SA MUST NOT NOTIFY THE FACILITY OR AO IN ADVANCE OF THE SURVEY 5. AREAS TO BE SURVEYED (FOR SAMPLE VALIDATION SURVEYS, CHECK ALL; FOR ALLEGATION SURVEYS, CHECK ALL APPLICABLE CONDITIONS, AND, IF APPLICABLE, THE LIFE SAFETY CODE STANDARD): 482.60(b) 482.11 482.12 482.13 482.21 482.22 482.23 482.25 482.26 482.27 482.28 482.30 COMPLIANCE WITH CoPS SPECIFIED IN §§482.1 THROUGH 482.23 AND §§482.25 THROUGH 482.57 FEDERAL, STATE AND LOCAL LAWS GOVERNING BODY PATIENT'S RIGHTS QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT MEDICAL STAFF NURSING SERVICES PHARMACEUTICAL SERVICES RADIOLOGIC SERVICES LABORATORY SERVICES FOOD AND DIETETIC SERVICES UTILIZATION REVIEW 482.41 482.41(b) 482.42 482.43 482.45 482.51 482.52 482.53 482.54 482.55 482.56 482.57 482.61 482.62 7. REGION PHYSICAL ENVIRONMENT LIFE SAFETY CODE INFECTION CONTROL DISCHARGE PLANNING ORGAN, TISSUE, & EYE PROCUREMENT SURGICAL SERVICES ANESTHESIA SERVICES NUCLEAR MEDICINE SERVICES OUTPATIENT SERVICES EMERGENCY SERVICES REHABILITATION SERVICES RESPIRATORY CARE SERVICES MEDICAL RECORD-REQUIREMENTS FOR PSYCH HOSPITALS SPECIAL STAFF REQUIREMENTS FOR PSYCH HOSPITALS 8. DATE Form CMS-2802F (11/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: OCSQ/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com