Form CMS-2802C (03/19)DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY HOME HEALTH AGENCY VALIDATION SURVEY1.Name and Address of State Agency2.Name and Address of Home Health AgencyCMS Certification Number:3.This HHA is currently deemed by (None or more than one [1] may be checked): ACHC CHAP TJC None 4.Check A or B. Do not check both.. 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 CertificationSurvey 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 [1] 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 andprocedures for a Medicare Certification Survey.SA must complete all Validation Packet documents listed in Exhibit 63 for any full Validation Survey.. This Validation Survey is based on allegations of significant deficiencies which could affect the health and safety ofpatients. Check one of the following: Potential IJ: Initiate Survey within two [2] working days; ORInitiate 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): 484.40Release of Patient Identifiable Information 484.45Reporting OASIS Data 484.50Patient Rights 484.55Comprehensive Assessment of Patients 484.60Care Planning, Coordination of Services and Quality of Care 484.65Quality Assessment and PerformanceImprovement 484.70Infection Prevention and Control 484.75Skilled Professional Services 484.80Home Health Aide Services 484.100Compliance with federal, state, and local laws and regulations related to the health and safety of patients 484.102Emergency Preparedness 484.105Organization and Administration of Services 484.110Contents of Clinical Record 484.115Personnel Qualifications 6.Signature of Regional Representative7.Region8.DateOriginal To: STATE SURVEY AGENCY Copies To: CMSO/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com