MHA Self-Assessment Checklists — Acute Care Hospitals

MHA has developed self-assessment checklists for acute care hospitals that will aid them 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.

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.

INTRODUCTION

Note: Unless otherwise noted, the checklists were last updated in August 2020.

• Anesthesia Services
• Discharge Planning (04/24)
• Emergency Services and Diversion
• EMTALA
• Food and Dietetic Services
• Governing Body
• Housekeeping Services
• Infection Prevention and Control and Antibiotic Stewardship Programs (04/24)
• Infectious Waste Management
• Laboratory Services
• Medical Record Services
• Medical Staff
• Nursing Services
• Obstetrics/Newborn
• Organ, Tissue and Eye Procurement
• Outpatient Services
• Patient Rights
• Pharmaceutical Services
• Physical Environment and Construction Standards
• Quality Assessment and Performance Improvement Program (4/24)
• Radiologic and Nuclear Medicine Services
• Rehabilitation Services
• Respiratory Services
• Surgical Services
• Swing Bed (4/24)
• UAP Training Program
• Utilization Review