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

Summary of Centers for Medicare & Medicaid Services (CMS) CoP CAH Updates as of November 2024

  • C-1220-C-1250
    Infection Prevention and Control, Antibiotic Stewardship was incorporated into the infection control standards. C-1220-C-1250 outlines Antibiotic Stewardship and Leadership Responsibilities. Additionally, the Joint Commission approved new and revised requirements for the "Infection Prevention and Control" chapter for CAH on July 1, 2024. The new requirements focus on CMS CoPs and the Centers for Disease Control and Prevention guidelines.
  • Medicare Promoting Interoperability Program
    CAHs participating in this program must meet updated requirements for electronic health record (EHR) reporting, including data on antimicrobial use and resistance surveillance.
  • Mandatory electronic reporting of respiratory virus data like COVID-19 and flu to CMS.
    Effective November 1, 2024, CMS will require hospitals and Critical Access Hospitals to electronically report information like confirmed infections and bed capacity, related to flu, COVID-19, and RSV, on a schedule specified by the Secretary of Health and Human Services.
  • C-1300-C-1325
    Updated Quality Assurance and Performance Improvement updates include updated staffing standards, quality assessments, and training requirements.
  • C-1400-C1430
    Addition of Discharge Planning CMS requirements.
  • C-1610
    New survey procedures for admission, transfer, and discharge rights.
  • C-1612
    Revision to content for freedom from abuse, neglect, and exploitation.
  • EHR access to medical records for the surveyors
    Electronic access to records will not eliminate the need for a surveyor to print a paper copy or to request a paper copy; however, the surveyor shall make reasonable efforts to avoid, when possible, printing medical records.
  • Suggestion to have policies in electronic format
    The Joint Commission (TJC) has encouraged organizations to provide electronic access to surveyors to policies and procedures and other required documents. You may consider uploading this to a shared drive with guest access. This approach has saved surveyors a lot of time searching in policies and has decreased the risk of the surveyor finding other areas of concern when reviewing policies. Note: When providing paper copies, always provide the current policy or document and highlight the information requested by the surveyor.
  • All new survey procedures have been added to the checklist for each chapter.
  • For CAH with TJC accreditation
    As of 2024, key updates include: revised patient rights and complaint resolution standards, new infection control guidelines with a focus on structure and quality, mandatory electronic reporting of respiratory virus data, and alignment with CMS CoP for consistent accreditation standards across CAHs; these changes primarily focus on improved patient safety and quality of care.