Authorization For State Agency Hospice Validation Survey {CMS-2802}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY HOSPITAL VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF HOSPITAL CMS CERTIFICATION NUMBER: _______________________________ 3. THIS HOSPITAL IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED) TJC AOA/HFAP DNV 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 ONE OR MORE OF THE FOLLOWING: THIS IS AN INITIAL ACCREDITATION SURVEY FOR THIS CURRENTLY PARTICIPATING, NON-DEEMED FACILITY. THIS IS AN INITIAL ACCREDITATION SURVEY FOR THIS AO; HOSPITAL IS CURRENTLY DEEMED. 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): 482.11 482.12 482.13 482.21 482.22 482.23 482.24 482.25 482.26 482.27 482.28 482.30 482.41 482.41(b) FEDERAL, STATE AND LOCAL LAWS GOVERNING BODY PATIENT'S RIGHTS QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT MEDICAL STAFF NURSING SERVICES MEDICAL RECORD SERVICES PHARMACEUTICAL SERVICES RADIOLOGIC SERVICES LABORATORY SERVICES FOOD AND DIETETIC SERVICES UTILIZATION REVIEW PHYSICAL ENVIRONMENT LIFE SAFETY CODE 482.42 482.43 482.45 482.51 482.52 482.53 482.54 482.55 482.56 482.57 INFECTION CONTROL DISCHARGE PLANNING ORGAN, TISSUE, & EYE PROCUREMENT SURGICAL SERVICES ANESTHESIA SERVICES NUCLEAR MEDICINE SERVICES OUTPATIENT SERVICES EMERGENCY SERVICES REHABILITATION SERVICES RESPIRATORY CARE SERVICES 6. SIGNATURE OF REGIONAL REPRESENTATIVE 7. REGION 8. DATE Form CMS-2802 (02/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMCS/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com