DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY HOSPICE VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF HOSPICE CMS CERTIFICATION NUMBER: ________________________________ 3. THIS HOSPICE IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED): ACHC CHAP TJC 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; HOSPICE 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): 418.52 418.54 418.56 418.58 418.60 418.62 418.64 418.66 418.70 418.72 418.74 418.76 418.78 PATIENT'S RIGHTS INITIAL/ COMPREHENSIVE ASSESSMENT OF THE PATIENTS INTERDISCIPLINARY GROUP, CARE PLANNING, AND COORDINATION QUALITY ASSESSMENT/ PERFORMANCE IMPROVEMENT INFECTION CONTROL LICENSED PROFESSIONAL SERVICES CORE SERVICES NURSING SERVICES--WAIVER FURNISHING OF NON-CORE SERVICES THERAPY SERVICES THERAPY & DIETARY ­WAIVER HOSPICE AIDE AND HOMEMAKER SERVICES VOLUNTEERS 418.114 418.116 418.100 418.102 418.104 418.106 418.108 418.110 ORGANIZATION AND ADMINISTRATION OF SERVICES MEDICAL DIRECTOR CLINICAL RECORDS DRUGS AND BIOLOGICALS, MEDICAL SUPPLIES AND DME SHORT-TERM INPATIENT CARE HOSPICES THAT PROVIDE INPATIENT CARE DIRECTLY 418.110(d) LIFE SAFETY CODE 418.112 HOSPICES THAT PROVIDE CARE TO SNF/NF OR ICF/MR RESIDENTS PERSONNEL QUALIFICATIONS COMPLIANCE WITH FEDERAL, STATE & LOCAL LAWS & REGULATIONS 6. SIGNATURE OF REGIONAL REPRESENTATIVE 7. REGION 8. DATE Form CMS-2802B (02/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMSO/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com