Form Cms-2802 - Request For Validation Of Accreditation
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1DEPARTMENT 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
DNV
AOA/HFAP
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
FEDERAL, STATE AND LOCAL LAWS
482.42
INFECTION CONTROL
482.12
GOVERNING BODY
482.43
DISCHARGE PLANNING
482.13
PATIENT’S RIGHTS
482.45
ORGAN, TISSUE, & EYE PROCUREMENT
482.21
QUALITY ASSESSMENT AND PERFORMANCE
482.51
SURGICAL SERVICES
IMPROVEMENT
482.52
ANESTHESIA SERVICES
482.22
MEDICAL STAFF
482.53
NUCLEAR MEDICINE SERVICES
482.23
NURSING SERVICES
482.54
OUTPATIENT SERVICES
482.24
MEDICAL RECORD SERVICES
482.55
EMERGENCY SERVICES
482.25
PHARMACEUTICAL SERVICES
482.56
REHABILITATION SERVICES
482.26
RADIOLOGIC SERVICES
482.57
RESPIRATORY CARE SERVICES
482.27
LABORATORY SERVICES
482.28
FOOD AND DIETETIC SERVICES
482.30
UTILIZATION REVIEW
482.41
PHYSICAL ENVIRONMENT
482.41(b)
LIFE SAFETY CODE
6. SIGNATURE OF REGIONAL REPRESENTATIVE
7. REGION
8. DATE
Form CMS-2802 (02/11)
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMCS/SCG/DACS
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