DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY CRITICAL ACCESS HOSPITAL (CAH) VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF CRITICAL ACCESS HOSPITAL CMS CERTIFICATION NUMBER: _______________________________ 3. THIS CAH IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED): AOA/HFAP 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; CAH 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): 485.608 485.610 485.612 485.616 485.618 485.620 485.623 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS STATUS AND LOCATION COMPLIANCE WITH HOSPITAL REQUIREMENTS AT THE TIME OF APPLICATION AGREEMENTS EMERGENCY SERVICES NUMBER OF BEDS AND LENGTH OF STAY PHYSICAL PLANT AND ENVIRONMENT 485.647 485.638 485.639 485.641 485.643 485.645 CLINICAL RECORDS SURGICAL SERVICES PERIODIC EVALUATION AND QUALITY ASSURANCE REVIEW ORGAN, TISSUE, AND EYE PROCUREMENT SPECIAL REQUIREMENTS FOR CAH PROVIDERS OF LONG-TERM CARE SERVICES (SWING-BEDS) PSYCHIATRIC AND REHABILIITATION DISTINCT PART UNITS 485.623(d) LIFE SAFETY CODE 485.627 485.631 485.635 ORGANIZATIONAL STRUCTURE STAFFING AND STAFF RESPONSIBILTIES PROVISION OF SERVICES 6. SIGNATURE OF REGIONAL REPRESENTATIVE 7. REGION 8. DATE Form CMS-2802E (02/11) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMSO/SCG/DACS American LegalNet, Inc. www.FormsWorkFlow.com