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Request For Validation Of Accrediation Survey For Home Health Agency CMS-2802C - Official Federal Forms
| Request For Validation Of Accrediation Survey For Home Health Agency Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT 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 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; 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): 484.4 484.10 484.11 484.12 484.14 484.16 484.18 484.20 484.30 PERSONNEL QUALIFICATION PATIENT'S RIGHTS RELEASE OF PATIENT IDENTIFIABLE OASIS INFO FEDERAL, STATE AND LOCAL LAWS ORGANIZATION, SERVICES AND ADMINISTRATION PROFESSIONAL PERSONNEL ACCEPTANCE OF PATIENTS, POC, & MEDICAL SUPERVISION REPORTING OF OASIS INFORMATION SKILLED NURSING SERVICES 484.48 484.52 484.55 484.32 484.34 484.36 484.38 THERAPY SERVICES MEDICAL SOCIAL SERVICES HOME HEALTH AIDE SERVICES QUALIFYING TO FURNISH OUTPATIENT PT OR SPEECH CLINICAL RECORDS EVALUATION OF THE AGENCY'S PROGRAM COMPREHENSIVE ASSESSMENT OF PATIENTS 6. SIGNATURE OF REGIONAL REPRESENTATIVE 7. REGION 8. DATE Form CMS-2802C (02/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMSO/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com
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