Form Cms-2802b - Request For Validation Of Accreditation Survey For Hospice
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
AUTHORIZATION FOR STATE AGENCY HOSPICE VALIDATION SURVEY
1. NAME AND ADDRESS OF STATE AGENCY
2. NAME AND ADDRESS OF HOSPICE
CMS CERTIFICATION NUMBER: ________________________________
3. THIS HOSPICE IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED):
ACHC
TJC
CHAP
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; HOSPICE 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, &, IF APPLICABLE, THE LIFE SAFETY CODE STANDARD):
418.52
PATIENT’S RIGHTS
418.100
ORGANIZATION AND ADMINISTRATION
OF SERVICES
418.54
INITIAL/ COMPREHENSIVE ASSESSMENT OF
THE PATIENTS
418.102
MEDICAL DIRECTOR
418.56
INTERDISCIPLINARY GROUP, CARE PLANNING,
418.104
CLINICAL RECORDS
AND COORDINATION
418.106
DRUGS AND BIOLOGICALS, MEDICAL SUPPLIES
418.58
QUALITY ASSESSMENT/ PERFORMANCE
AND DME
IMPROVEMENT
418.108
SHORT-TERM INPATIENT CARE
418.60
INFECTION CONTROL
418.110
HOSPICES THAT PROVIDE INPATIENT
418.62
LICENSED PROFESSIONAL SERVICES
CARE DIRECTLY
418.64
CORE SERVICES
418.110(d) LIFE SAFETY CODE
418.66
NURSING SERVICES—WAIVER
418.112
HOSPICES THAT PROVIDE CARE TO SNF/NF OR
418.70
FURNISHING OF NON-CORE SERVICES
ICF/MR RESIDENTS
418.72
THERAPY SERVICES
418.114
PERSONNEL QUALIFICATIONS
418.74
THERAPY & DIETARY –WAIVER
418.116
COMPLIANCE WITH FEDERAL, STATE & LOCAL
418.76
HOSPICE AIDE AND HOMEMAKER SERVICES
LAWS & REGULATIONS
418.78
VOLUNTEERS
6. SIGNATURE OF REGIONAL REPRESENTATIVE
7. REGION
8. DATE
Form CMS-2802B (02/11)
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMSO/SCG/DACS
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