North Dakota Critical Access Hospital Conditions of Participation (CoP) Checklist

Updated November 2024

The contents of this CoP checklist reflect the opinion of the North Dakota CAH Quality Network only. This publication is for informational purposes. It is meant to be a tool to assist CAH Network Members with the Centers for Medicare and Medicaid (CMS) State Operations Manual - Appendix W and North Dakota State Regulations Chapter 33-07-01.1 (Hospitals) .

The North Dakota CoP Checklist is not inclusive, and the specific tag and licensing references should be reviewed to ensure each CAH understands and complies with all parts of the regulation/rules. Please use the checklist in conjunction with other resources. Other regulations may also apply that are not included in this document (i.e., Pharmacy, Life Safety Codes). The North Dakota CAH Quality Network is not able to ensure the following document remains current as changes and updates are initiated.

In this Checklist

• Summary of CMS CoP CAH Updates as of November 2024
• Survey Preparation
• General Survey Protocol
• Critical Access Hospital (CAH) Survey Information Request Sheet
• Tags and Requirements
• Abbreviations

This checklist is also available in a printable PDF.

The CoP Checklist document is created from lectures, ideas and information captured by Gayle Nash, RN, MPH, President, Nash Healthcare Consulting, and Nash Healthcare Clinical Consulting Team.

A special Thank You to Shelly Heilman at the North Dakota Department of Health and Human Service for her collaboration in ensuring accuracy to parts of this document and her ongoing support to the ND CAH Quality Network.