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 (11/21)
• Anesthesia and Post-Anesthesia Recovery Services (9/16)
• Central Service (9/14)
• Clinical Records (11/21)
• Criteria to be a CAH (11/21)
• Discharge Planning and Social Work Services (5/16)
• Emergency Preparedness (10/17)
• Emergency Services and Diversion (1/22)
• EMTALA (6/16)
• Fire Safety, General Safety and Operating Features (7/16)
• Food and Dietetic Services (5/16)
• Housekeeping and Laundry (9/14)
• Infection Prevention and Control Antibiotic Stewardship Programs (8/22)
  
• Laboratory Services (5/16)
  
• Medical Record Services (5/16)
• Medical Services (9/14)
  
• Miscellaneous Missouri Regulations (9/14)
  
• Number of Beds and Length of Stay (5/22)
• Nursing Services (5/16)
  
• Obstetrical Services (3/16)
  
• Organ Donation
• Orientation and Continuing Education (9/14)
• Outpatient Services (5/16)
• Patient Rights (9/16)
  
• Pediatric Services (3/15)
  
• Pharmacology Services (11/16)
• Psychiatric Services (9/16)
  
• Quality Improvement Services (5/16)
• Radiology and Nuclear Medicine Services (9/16)
  
• Rehabilitation Services (Rehab, PT, OT, Audiology and ST) (9/16)
• Respiratory Services (5/16)
  
• Safe Patient Handling (9/14)
  
• Specialized Inpatient Care Unit (9/14)
  
• Surgical Services (1/21)
• Telemedicine (11/21)
• Unlicensed Assistive Personnel (9/14)
  
• Utilization Review (5/16))
• Waste Management (9/14)