Form Cms-2802d - Request For Validation Of Accreditation Survey For Ambulatory Surgical Center

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
AUTHORIZATION FOR STATE AGENCY AMBULATORY SURGICAL CENTER (ASC)
VALIDATION SURVEY
1. NAME AND ADDRESS OF STATE AGENCY
2. NAME AND ADDRESS OF AMBULATORY SURGICAL CENTER
CMS CERTIFICATION NUMBER: ________________________________
3. THIS ASC IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED)
AAAASF
AAAHC
NONE
AOA/HFAP
TJC
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; ASC 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):
416.25
BASIC REQUIREMENTS
416.47
MEDICAL RECORDS
416.40
STATE LICENSURE LAWS
416.48
PHARMACEUTICAL SERVICES
416.41
GOVERNING BODY AND MANAGEMENT
416.49
LABORATORY & RADIOLOGIC
SERVICES
416.42
SURGICAL SERVICES
416.50
PATIENT RIGHTS
416.43
QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT
416.51
INFECTION CONTROL416.51
INFECTION CONTROL
416.44
ENVIRONMENT
416.52
PATIENT ADMISSION,
416.44(b) LIFE SAFETY CODE
ASSESSMENT & DISCHARGE
416.45
MEDICAL STAFF
416.46
NURSING SERVICES
6. SIGNATURE OF REGIONAL REPRESENTATIVE
7. REGION
8. DATE
Form CMS-2802D (02/11)
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMSO/SGC/DACS

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