Critical Access Hospital (CAH) Survey Information Request Sheet

North Dakota Department of Health Division of Health Facilities

To expedite the survey, the following information will be needed (please label information with the corresponding number from the list): 1. Electronic medical record access for two surveyors.

Within 1 Hour:

1. Electronic medical record access for two surveyors.
2. List of department heads with contact information. A copy for each surveyor.
3. Facility floor plan.
4. List of all current hospital patients (including inpatients, swing bed, observation patients) – providing each patient’s name, room number, diagnosis(es), admission date, age, attending physician, and patient’s status. A copy for each surveyor.
5. Two copies of medical staff bylaws that have been signed and approved.
6. Three copies of the medical staff rules and regulations that have been signed and approved.
7. Computerized register/listing for inpatient admissions from the past six months to the current date. Please include the patient’s name, medical records number, age and/or birthdate, date of admit, date of discharge and/or death, attending physician, and diagnosis(es).
8. Computerized register/listing or log book for emergency room patients from the past three months to current date. Please include the patient’s name, medical record number, age and/or birthdate, date and time of service, provider name, disposition, and chief complaint.
9. Computerized register/listing or logbook for surgical patients from the past six months to current date. Pleaseinclude the patient’s name, medical record number, age and/or birthdate, date of operation, type of operation, type of anesthesia, name of the surgeon.
10. Computerized register/listing or log book for all swing bed patients from the past six months to current date. Please include the patient’s name, medical record number, age and/or birthdate, date of admit, date of discharge and/or death, attending physician, and diagnosis(es).
11. List of patient deaths in the last six months. Please include: Name, medical records number, birthdate, date of death, provider, and diagnosis(es).
12. The names and addresses of all offsite locations and clinics operating under the same provider number. Identify if any of the off-site locations bill any services (e.g., lab, radiology, therapy) under the hospital’s provider number.
13. Incident and accident (variance) reports from the past six months.
14. Three copies of a listing of all current medical staff (identify medical staff officers and categories: active, courtesy, consulting, locum tenens, telemedicine, etc.).
15. Two copies of Governing Body bylaws that have been signed and approved.
16. Medical staff meeting minutes for the past twelve months.
17. Governing Body minutes for the past twelve months.

Within 4 hours:

18. Committee meeting minutes for the past twelve months (i.e., Quality Assurance/Improvement, Pharmacy & Therapeutics, Safety, etc.)
19. One copy (not original) of the approved quality assurance/improvement plan and reporting schedule for the current year and the past year. QA reports from last year.
20. Infection Control Program (infection control log, reports, meeting minutes, etc.).
21. A copy of the waterborne pathogens (including Legionella) risk assessment.
22. A copy of the network agreement(s) and copy of credential agreement(s).
23. A copy of agreement(s) for telemedicine and teleradiology and lists provided by the distant site hospital/entity of the telemedicine providers.
24. A copy of the list of services the facility provides directly.
25. A copy of the listing of contracted services (provided by arrangements/agreements) and the scope of services provided.
26. Dietary menus for one month including all diets offered.
27. Advance Directive information: written information provided to patient/resident and evidence that the facility has provided advance directive education for staff and the community.
28. Admission material provided to acute patients and swing bed patients.
29. Organ procurement policies/procedures, copy of agreement with organ procurement agency, and documentation of staff training.
30. Copy of schedule for ER medical providers for the past 6 months.
31. Call schedules for laboratory, radiology, etc., for the past three months.
32. Organization chart.
33. A list of all current governing body members and officers. One copy (not original).
34. List of all CAH employees (including contracted staff and volunteers) – provide name, title/position, department, and vaccine/exemption status. Identify any staff hired within the last 60 days. A copy for each surveyor.
35. Evidence of biomedical equipment inspections for the last quarter.
36. Copy of contract with an ambulance service (if not hospital owned).

Available Upon Request of Surveyor:

37. Policies and procedures for each department of the hospital. Consider uploading all current policies and procedures to a shared drive for surveyors.
38. Personnel files of specified employees (licenses/certifications, orientation for new employees/new programs, and annual education training).
39. Pharmacist registration number and annual Board of Pharmacy hospital inspection report and plan of correction if applicable.
40. Contracts with outside resources and any applicable reports.