Form Cms-2802c - Request For Validation Of Accreditation Survey For Home Health Agency
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
AUTHORIZATION FOR STATE AGENCY HOME HEALTH AGENCY
VALIDATION SURVEY
1. NAME AND ADDRESS OF STATE AGENCY
2. NAME AND ADDRESS OF HOME HEALTH AGENCY
CMS CERTIFICATION NUMBER: _______________________________
3. THIS HHA IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED):
ACHC
CHAP
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 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; HHA 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):
484.4
PERSONNEL QUALIFICATION
484.32
THERAPY SERVICES
484.10
PATIENT’S RIGHTS
484.34
MEDICAL SOCIAL SERVICES
484.11
RELEASE OF PATIENT IDENTIFIABLE OASIS INFO
484.36
HOME HEALTH AIDE SERVICES
484.12
FEDERAL, STATE AND LOCAL LAWS
484.38
QUALIFYING TO FURNISH OUTPATIENT
PT OR SPEECH
484.14
ORGANIZATION, SERVICES AND ADMINISTRATION
484.48
CLINICAL RECORDS
484.16
PROFESSIONAL PERSONNEL
484.52
EVALUATION OF THE AGENCY’S
484.18
ACCEPTANCE OF PATIENTS, POC, & MEDICAL
PROGRAM
SUPERVISION
484.55
COMPREHENSIVE ASSESSMENT
484.20
REPORTING OF OASIS INFORMATION
OF PATIENTS
484.30
SKILLED NURSING SERVICES
6. SIGNATURE OF REGIONAL REPRESENTATIVE
7. REGION
8. DATE
Form CMS-2802C (02/11)
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMSO/SCG/DACS
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