Form Cms-2802e - Request For Validation Of Accreditation For Critical Access Hospital Survey
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
AUTHORIZATION FOR STATE AGENCY CRITICAL ACCESS HOSPITAL (CAH)
VALIDATION SURVEY
1. NAME AND ADDRESS OF STATE AGENCY
2. NAME AND ADDRESS OF CRITICAL ACCESS HOSPITAL
CMS CERTIFICATION NUMBER: _______________________________
3. THIS CAH IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED):
AOA/HFAP
NONE
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; CAH 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):
485.608
COMPLIANCE WITH FEDERAL, STATE, AND
485.638
CLINICAL RECORDS
LOCAL LAWS
485.639
SURGICAL SERVICES
485.610
STATUS AND LOCATION
485.641
PERIODIC EVALUATION AND QUALITY
485.612
COMPLIANCE WITH HOSPITAL REQUIREMENTS AT
ASSURANCE REVIEW
THE TIME OF APPLICATION
485.643
ORGAN, TISSUE, AND EYE PROCUREMENT
485.616
AGREEMENTS
485.645
SPECIAL REQUIREMENTS FOR CAH
485.618
EMERGENCY SERVICES
PROVIDERS OF LONG-TERM CARE
SERVICES (SWING-BEDS)
485.620
NUMBER OF BEDS AND LENGTH OF STAY
485.647
PSYCHIATRIC AND REHABILIITATION
485.623
PHYSICAL PLANT AND ENVIRONMENT
DISTINCT PART UNITS
485.623(d) LIFE SAFETY CODE
485.627
ORGANIZATIONAL STRUCTURE
485.631
STAFFING AND STAFF RESPONSIBILTIES
485.635
PROVISION OF SERVICES
6. SIGNATURE OF REGIONAL REPRESENTATIVE
7. REGION
8. DATE
Form CMS-2802E (02/11)
ORIGINAL TO: STATE SURVEY AGENCY
COPIES TO: CMSO/SCG/DACS
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