A self-assessment checklist developed by MHA will aid acute care hospitals with their internal assessments of their compliance with state hospital licensure regulations, Medicare Conditions of Participation (CoPs) for hospitals and the interpretative guidelines to the CoPs. These tools may help hospitals improve staff knowledge of the regulations, decentralize the responsibility for regulatory compliance from the administrative offices to all department managers. In addition, these tools will help staff proactively identify and correct regulatory issues to improve compliance and as well as decrease the number and length of surveys and cited deficiencies.

The checklists included in this document are applicable to all hospitals except critical access hospitals. Although CAHs are subject to the same state hospital licensure regulations, they have unique CoPs. Checklists specific to CAHs are being developed and will be published in the near future.

These checklists are being distributed solely for informational purposes and are not intended to serve as an interpretation to the regulations. The Missouri Department of Health and Senior Services’ Division of Regulation and Licensure is responsible for interpreting and enforcing these regulations. If you have questions about the regulations, please contact the appropriate state and/or federal agency.

MHA staff hopes these checklists will assist your hospital in achieving and maintaining continuous survey readiness and compliance with the state hospital licensure regulations and the Medicare CoPs. If you have questions, please contact Sharon Burnett.

Self-Assessment Checklist for Acute Care Hospitals

Introduction
Section 1: Governing Body, CEO, Medical Staff (updated March 2008)
Section 2: Patient Rights (updated March 2008)
Section 3: Quality Improvement Services (updated March 2008)
Section 4: Medical Services (updated March 2008)
Section 5: Nursing Services (updated March 2008)
Section 6: Medical Record Services (updated March 2008)
Section 7: Pharmacology Services (updated March 2008)
Section 8: Radiology and Nuclear Medicine Services (updated March 2008)
Section 9: Laboratory Services (updated March 2008)
Section 10: Food and Dietetic Services (updated March 2008)
Section 11: Utilization Review
Section 12: Fire Safety, General Safety and Operating Features (updated March 2008)
Section 13: Central Service (updated March 2008)
Section 14: Housekeeping (updated March 2008)
Section 15: Laundry and Linen Services (updated March 2008)
Section 16: Infectious Waste Management (updated March 2008)
Section 17: Discharge Planning and Social Work Services (updated March 2008)
Section 18: Infection Control (updated March 2008)
Section 19: Organ Donation
Section 20: Emergency Services (updated March 2008)
Section 21: EMTALA (updated March 2008)
Section 22: Orientation and Continuing Education (updated March 2008)
Section 23: Surgical Services (updated March 2008)
Section 24: Anesthesia and Post-Anesthesia Recovery Services (updated March 2008)
Section 25: Ambulatory Care Services (updated March 2008)
Section 26: Respiratory Services (updated March 2008)
Section 27: Rehabilitation Services (Rehab, PT, OT, Audiology and ST) (updated March 2008)
Section 28: Obstetrical Services (updated March 2008)
Section 29: Pediatric Services (updated March 2008)
Section 30: Psychiatric Services (updated March 2008)

Self-Assessment Checklist for Critical Access Hospitals