MHA Self-Assessment Checklists — Critical Access Hospitals

MHA has developed self-assessment checklists for critical access 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.

• Agreements (2/24)
• Clinical Records (2/24)
• Compliance at Application Time (3/24)
• Compliance with Federal State and Local Laws and Regulations (3/24)
• Criteria to be a CAH (11/21)
• Designation and Certification (3/24)
• Discharge Planning (1/24)
• Emergency Preparedness (1/24)
• Emergency Services (2/24)
• EMTALA (3/24)
• Infection Prevention and Control and Antibiotic Stewardship Programs (2/24)
• Number of Beds and Length of Stay (1/24)
• Organ, Tissue and Eye Procurement (2/24)
• Organizational Structure (2/24)
• Patient Rights (3/24)
• Personnel Requirements (3/24)
• Physical Plant and Environment and Constructions Standards for New Hospitals (2/24)
• Provision of Services (2/24)
• Psychiatric and Rehabilitation Distinct Part Unit (3/24)
• Quality Assessment and Performance Improvement Program (2/24)
• Rural Health Network (3/24)
• Staffing and Staffing Responsibilities (1/24)
• Status and Location (3/24)
• Surgical Services (2/24)
• Swing Bed (4/24)
• Telemedicine (2/24)
• UAP Training Program (3/24)
• Unlicensed Assistive Personnel (9/14)