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Policy Approval – Critical Access Hospitals

Policy Approval – Critical Access Hospitals

Question:

Is there a CMS regulation that requires a critical access hospital’s patient care policies and procedures to be approved by the governing body?

Answer:

Yes, the Governing Body of a Critical Access Hospital or individual responsible for the CAH, consistent with the requirement at §485.627(a) must review and approve patient care policies and procedures.

The CMS regulations are as follows:

  • 485.635(a)(2) – patient care policies are developed with the advice of members of the critical access hospital’s (CAH) professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1).
  • 485.635(a)(4) – patient care policies are reviewed at least annually by the group of professional personnel and reviewed as necessary by the CAH.
    • The CAH’s written policies governing patient care services must be developed with the advice of members of the CAHs professional healthcare staff. This advisory group must include:
      • At least one MD or DO; and
      • One or more physician assistants, nurse practitioners, or clinical nurse specialists, at least one of these non-physician practitioners if these professionals are included in the CAH’s healthcare staff, as permitted at §485.631(a)(1).
      • A CAH with no non-physician practitioners on staff is not required to obtain the services of an outside non-physician practitioner to serve on the advisory group.
      • The advisory group not only makes recommendations for new CAH patient care policies, but is also expected to review the existing patient care policies at least annually and, if it concludes that changes are needed, recommend those changes.
      • Policies must be reviewed and, as applicable, revised more frequently when required, for example, in response to a change in Federal or State regulations to which the CAH is subject.

Remember that critical access hospitals must maintain documentation that provides evidence that the advisory group has conducted its reviews and made recommendations concerning patient care policies.

Although a CAH’s patient care policies are developed and periodically reviewed with the advice of members of the CAH’s professional healthcare staff, the final decision on the content of the written policies is made by the CAH’s governing body or individual responsible for the CAH, consistent with the requirement at §485.627(a). If recommendations of the advisory group are rejected, the governing body must include in the record of its adoption of the final written policies its rationale for adopting a different policy than that recommended.

Ensure that your critical access hospital has documentation showing that the advisory group developed written recommendations on the CAH’s patient care policies for consideration by the CAH’s governing body/responsible individual.  A critical access hospital must also be able to show that the advisory group reviewed the CAH’s existing policies at least annually and indicated whether or not it recommended any changes.

Related Products from MCN Healthcare:

MCN Healthcare’s Policy Management Software

Administrative Manual for Critical Access Hospitals

MCN HEALTHCARE

Regulatory Compliance Solutions for Healthcare Organizations,
Including Policy Management SoftwarePolicy Library Templates,
StayAlert! – Regulatory Alert System, and Learning Management System

www.mcnhealthcare.com

Free COVID-19 Resources: Click Here to Access StayAlert! | Click Here for Additional Resources

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