DEPARTMENTOF 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  JCAHO  AOA 4. DATE ALLEGATION REPORTED 5. DATE CASE CLOSED TO CMS 6. SOURCE OF ALLEGATION (CHECK ALLAPPLICABLE BOXES)  CONGRESSIONALINQUIRY  MEDICAID REPORT  PATIENTOR PATIENTS FAMILY  MEDICARE INTERMEDIARY  HOSPITAL OR EX-HOSPITAL STAFF  PEER REVIEW ORGANIZATION (PRO)  NEWS MEDIA  OTHER (SPECIFY)  LICENSURE REPORT  STATE INSURANCE COMMISSIONER 7. REGIONALOFFICE SCREENING AND REFERRALS (CHECK ALLAPPLICABLE BOXES)  NO INVESTIGATION WARRANTED  REFERRED FOR INVESTIGATION  STATE AGENCY(COMPLETE ITEM 8)  STATE LICENSURE  OTHER  PRO  INSPECTOR GENERAL  MEDICARE INTERMEDIARY  DEPARTMENTOF JUSTICE 8. AREAOF STATE AGENCYINVESTIGATION (CHECK ALLAPPLICABLE BOXES)  FEDERAL, STATE, AND LOCALLAWS  UTILIZATION REVIEW  GOVERNING BODY  PHYSICALENVIRONMENT  QUALITYASSURANCE  LSC  MEDICALSTAFF  INFECTION CONTROL  NURSING SERVICES  SURGICALSERVICES  MEDICALRECORD SERVICES  ANESTHESIASERVICES  PHARMACEUTICALSERVICES  NUCLEAR MEDICINE SERVICES  RADIOLOGIC SERVICES  OUTPATIENTSERVICES  LABORATORY SERVICES  EMERGENCYSERVICES  FATAL TRANSFUSION REACTION  REHABILITATION SERVICES  FOOD AND DIETETIC SERVICES  RESPIRATORY CARE SERVICES 9. FINDINGS a.  IN COMPLIANCE WITH CONDITION(S) OF PARTICIPATION b.  OUT OF COMPLIANCE WITH CONDITION(S) OF PARTICIPATION 1.  HOSPITAL PLACED UNDER STATE AGENCYSURVEY JURISDICTION 2.  TERMINATION IN PROGRESS 10. REMARKS 11. SIGNATURE OF REGIONALREPRESENTATIVE 12. REGION 13. DATE Form CMS-2878 (04/86) COPIES:HOSPITAL SERVICES BRANCH,BALTO., MD American LegalNet, Inc. DHSQ - RO CONTROL FILE www.USCourtForms.com