DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY AMBULATORY SURGICAL CENTER (ASC) VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF AMBULATORY SURGICAL CENTER CMS CERTIFICATION NUMBER: ________________________________ 3. THIS ASC IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED) AAAASF AOA/HFAP AAAHC 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; ASC 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): 416.25 416.40 416.41 416.42 416.43 416.44 BASIC REQUIREMENTS STATE LICENSURE LAWS GOVERNING BODY AND MANAGEMENT SURGICAL SERVICES QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT ENVIRONMENT 416.52 416.50 416.51 416.47 416.48 416.49 MEDICAL RECORDS PHARMACEUTICAL SERVICES LABORATORY & RADIOLOGIC SERVICES PATIENT RIGHTS INFECTION CONTROL416.51 INFECTION CONTROL PATIENT ADMISSION, ASSESSMENT & DISCHARGE 416.44(b) LIFE SAFETY CODE 416.45 416.46 MEDICAL STAFF NURSING SERVICES 6. SIGNATURE OF REGIONAL REPRESENTATIVE 7. REGION 8. DATE Form CMS-2802D (02/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMSO/SGC/DACS American LegalNet, Inc. www.FormsWorkFlow.com