Form Cms-2878 - Accredited Hospital Allegations Report
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
ACCREDITED HOSPITAL ALLEGATION(S) REPORT
1. NAME AND ADDRESS OF HOSPITAL
2. PROVIDER NUMBER
3. HOSPITAL ACCREDITED BY
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JCAHO
AOA
4. DATE ALLEGATION REPORTED
5. DATE CASE CLOSED
TO CMS
6. SOURCE OF ALLEGATION (CHECK ALL APPLICABLE BOXES)
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CONGRESSIONAL INQUIRY
MEDICAID REPORT
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PATIENT OR PATIENT'S FAMILY
MEDICARE INTERMEDIARY
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HOSPITAL OR EX-HOSPITAL STAFF
PEER REVIEW ORGANIZATION (PRO)
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NEWS MEDIA
OTHER (SPECIFY)
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LICENSURE REPORT
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STATE INSURANCE COMMISSIONER
7. REGIONAL OFFICE SCREENING AND REFERRALS (CHECK ALL APPLICABLE BOXES)
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NO INVESTIGATION WARRANTED
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REFERRED FOR INVESTIGATION
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STATE AGENCY (COMPLETE ITEM 8)
OTHER
STATE LICENSURE
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PRO
INSPECTOR GENERAL
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MEDICARE INTERMEDIARY
DEPARTMENT OF JUSTICE
8. AREA OF STATE AGENCY INVESTIGATION (CHECK ALL APPLICABLE BOXES)
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FEDERAL, STATE, AND LOCAL LAWS
UTILIZATION REVIEW
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GOVERNING BODY
PHYSICAL ENVIRONMENT
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QUALITY ASSURANCE
LSC
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MEDICAL STAFF
INFECTION CONTROL
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NURSING SERVICES
SURGICAL SERVICES
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MEDICAL RECORD SERVICES
ANESTHESIA SERVICES
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PHARMACEUTICAL SERVICES
NUCLEAR MEDICINE SERVICES
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RADIOLOGIC SERVICES
OUTPATIENT SERVICES
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LABORATORY SERVICES
EMERGENCY SERVICES
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FATAL TRANSFUSION REACTION
REHABILITATION SERVICES
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FOOD AND DIETETIC SERVICES
RESPIRATORY CARE SERVICES
9. FINDINGS
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a.
IN COMPLIANCE WITH CONDITION(S) OF PARTICIPATION
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b.
OUT OF COMPLIANCE WITH CONDITION(S) OF PARTICIPATION
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1.
HOSPITAL PLACED UNDER STATE AGENCY SURVEY JURISDICTION
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2.
TERMINATION IN PROGRESS
10. REMARKS
11. SIGNATURE OF REGIONAL REPRESENTATIVE
12. REGION
13. DATE
Form CMS-2878 (04/86)
COPIES: HOSPITAL SERVICES BRANCH, BALTO., MD
DHSQ - RO CONTROL FILE
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Parent category: Medical