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Evaluation of a Critical Access Hospital’s Programs

MCN Question of the Week

Evaluation of a Critical Access Hospital’s Programs

QUESTION:

Per CMS regulations, how often must a Critical Access Hospital evaluate its programs?

ANSWER:

CMS regulation §485.641(a) addresses the periodic evaluation of a Critical Access Hospital’s (CAH) programs.

The CAH must carry out or arrange for a periodic evaluation of its total program at least once a year and includes review of:

  • The utilization of CAH services, including at least the number of patients served and the volume of services
  • A representative sample of both active and closed clinical records; and
    • A representative sample of both active and closed clinical records” means not less than 10 percent of both active and closed patient records.
  • The CAH’S health care policies.

The purpose of the evaluation is to determine whether the utilization of services is appropriate, the established policies are followed, and if any changes are needed.

Ensure your CAH can answer the following:

  • How is information obtained to be included in the periodic evaluation?
  • How does the CAH conduct the periodic evaluation?
  • Who is responsible for conducting the periodic evaluation?
  • How does the CAH ensure that the yearly program evaluation includes a review of all CAH services, the number of patients served and the volume of services provided
  • Who is responsible for the review of both active and closed clinical records?
  • How are records selected and reviewed in the periodic evaluation?
  • How does the evaluation process ensure that the sample of records is representative of services furnished?
  • What criteria are utilized in the review of both active and closed records?
  • What evidence demonstrates that the health care policies of the CAH are evaluated, reviewed and/or revised as part of the annual program evaluation?
  • How does the CAH use the results of the yearly program evaluation?
  • Were policies, procedures and /or facility practices added, deleted or revised as a result of the yearly program evaluation if needed?

Related Products from MCN Healthcare

Administrative Manual for Critical Access Hospitals

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Regulatory Compliance Solutions for Healthcare Organizations,
Including Policy Management Software, Policy Library Templates,
StayAlert! – Regulatory Alert System, and Learning Management Systemwww.mcnhealthcare.com

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