Compliance Monitoring Division
Clarifications for Critical Access Hospitals
Updated June 17, 2005
Responses are in bold. Some web references are included in some of the answers.
1. Q: C-0152: Would this tag be issued if there were no criminal background checks for MD, CRNA- all except CNAs?
A: This tag would be issued if no background studies for any person providing direct care, which would include CNAs or any other title having direct care to the patient. MN Statues, Sections 245A.04, Subd. 3. Background study. Individuals and organizations that are required under section 245C.03 to have or initiate background studies shall comply with the requirements in chapter 245C. and 144.057 Background studies on licensees and supplemental nursing services agency personnel. Subdivision 1. Background studies required. The commissioner of health shall contract with the commissioner of human services to conduct background studies of: (1) individuals providing services which have direct contact, as defined under section 245C.02 , subdivision 11. (Subd. 11. Direct contact. "Direct contact" means providing face-to-face care, training, supervision, counseling, consultation, or medication assistance to persons served by the program.)
2. Question: C-0191- Does the CAH need a log of their communication with network hospitals?
Answer: The survey procedures under C-0191 asks the question under the bullet “Is a communications log kept at the facility?” If the answer is “No” from the facility, the system that the facility uses would need to be explained.
3. Question: C-0211 Will surveyors actually count the number of beds in the CAH?
Answer: Yes, surveyors are to count the number of beds. Cannot be over 25 patient beds (if certified for 25). Outpatient bed would be counted depending on the type of beds that are. Beds capable of being used as inpatient acute care beds (i.e. a typical hospital bed) would be counted toward the 25-bed limit. Other types of bed (cots, gurneys, etc.) would not be counted.
4. Question: C-0285 - When would surveyors issue this tag?
Answer: C-0285 would probably be issued when the majority of the elements under that Standard (C-0286 to C-293) are not met. That tag has not been issued to date.
5. Question: C-0291 - Does the CAH need a list of contracted services with nature and scope or would the contract be sufficient if it addresses the nature and scope of the service?
Answer: Yes, the list needs to be maintained as that is a regulatory requirement.
6. Question: C-0292 - When would surveyors issue this tag?
Answer: This has not been issued yet. Would be issued if there were problems identified with services provided through arrangements or agreements and the facility had not identified the person responsible.
7. Question: C-0294 - Would surveyors issue this tag if they had identified problems with pool nurses?
Answer: Yes, the IGs under this tag addresses: all non-CAH nursing personnel and includes agency staff (pool).
8. Question: C-0304 - In the IG, last bullet indicates, “10% of average daily census”- is that an error-should it be 10% of the annual census?
Answer: This has been sent to CMS and clarification has been asked for. Surveyors are told to look at enough records to ensure compliance. Looking at 10% of average daily census when the average daily census is 14 or 15 would mean only reviewing 2 records and compliance may not be able to be determined.
9. Question: C-0311- Does Minnesota require records to be kept for 7 years?
Answer: MN Rule 145.32 and 145.30. After 3 years records can be microfilmed and then destroyed. We are allowing records to be computerized without any paper records as long as storage is permanent. Paper: a complete record for 7 years, after that these portions must be kept permanently: Those are: Outpatient diagnostic and lab results; discharge summary, history and physical, op reports, path reports, anesthesia reports, autopsy reports. Records of minors, all portions at least 7 years from age of majority.
10. Question: C-0338 Does this tag mean QA for medication therapy utilized for nosocomial infections or does it mean QA for medication therapy and QA for nosocomial infections?
Answer: This is currently be interrupted as QA for medication therapy utilized for nosocomial infections and a QA for nosocomial infections. QA for other medication therapy would be issued under C-0337 or C-0276 (Rules for drugs and biologicals.
11. Question: C-0388 - What is meant by, “structural problems” at viii?
Answer: Refers to the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities.
12. Question: C-0389 - If a resident is not in a swing bed for 14 days, does all the required assessment information need to be in the discharge summary?
Answer: Depends, the intent of this regulation is to assess residents in a timely manner. Surveyors will expect that the resident has been assessed to met the resident's needs and when discharged that information is included in the discharge summary.
13. Question: C-0397 - When would this tag be issued?
Answer: The IGs address the intent of this.
14. Question: C-0398 - Would this tag be issued if the care plan identifies something but the surveyors do not see it being provided for the swing bed resident?
Answer: Yes, or if services are seen provided and that staff is not a qualified person to provide that service.
15. Question: C-0404 - Would a dentist need to be credentialed if the dentist does not provide services on site to residents?
Answer: No. However, must hospitals do credential the dentist.
16. Question: If the MD/DO is not involved in policy review, development, and revision where would surveyors issue the deficiency 258, 272, or 280?
Answer: C-0258 is the most specific for MD/DO involvement and the first choice. C-0272 describes the group and C-0280 describes the frequency of policy review.
17. Question: If a midlevel practitioner is on staff and is not involved in policy review, development and revision where would surveyors issue the deficiency 263, 272, or 280?
Answer: C-0263 is the most specific for mid-level involvement and the first choice. C-0272 describes the group and C-0280 describes the frequency of policy review.
18. Question: Would QA for maintenance be issued at 220 or 337 if QA was not done?
Answer: C-0220 is the CoP for Physical Plant and Environment. If nothing had been incorporated into the CAH QA program the CoP might be the most appropriate tag to issue. However, if parts were done, but the routine and preventive maintenance and testing had not been incorporated in the QA plan, then perhaps C-0222 would be cited.
19. Question: Where would unlocked toxics be issued if found by surveyors?
Answer: Toxics that are unlocked are most often chemicals used in housekeeping and if problems found then C-0222 would be appropriate.
20. Question: Where would unlocked drugs be issued if found by surveyors?
Answer: Under C-0276.
21. Question: If the survey team identified an EMTALA violation do they report it to OHFC to follow up with an investigation? Do they inform the facility they have identified an EMTALA violation?
Answer: Yes, they would report a concern to OHFC. They would not inform the facility as only after an investigation is completed by OHFC is the determination made if an EMTALA violation is made.
22. Question: What would be an acceptable QA for organ procurement?
Answer: Usually as part of OPO agreement, the OPO reviews the death records and information is relayed back to the facility to follow up. The facility incorporates that info into the QA process.
23. Question: Could CAH utilize Information Bulletin 04-18 when doing a POC?
Answer: Although IB-04-18 is specifically for Skilled Nursing Facilities and Nursing Facilities the CAH could utilize the IB. The components of a plan of correction (PoC) are the components needed for a CAH PoC also.
24. Question: Could CAH utilize QAPI for hospitals (42 CFR 482.21) for a guideline when doing QA?
Answer: QAPI is currently not required for CAHs. There has been general discussion that QAPI will be a requirement in the future. The CAH may use if they determine is helpful to their QA process.
25. Question: Could CAH utilize CMS S&C-05-04 for guidance when developing the CAH credentialing system?
Answer: Yes, they could, but are not required to. The CAH is 42 CFR 485. CMS S&C-05-04 applies to hospital CoPs at 42 CFR 482.
26. Question: What are the humidity requirements for the operation room?
Answer: There is no regulatory requirement under C-0226 for humidity levels. However in the IGs talk about acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA)
should be incorporated into CAH policy. Here is a web site for AORN:
27. Question: At the CAH survey training, an issue that came up at all the sessions were peer review of physicians and whether it needed to be done by someone outside of the CAH.
Answer: The answer is yes, but you are allowed to just send a portion of records or "outliers" if you have a system clearly described in your policies
and procedures that indicates the process for determining them. A group that is providing outside medical peer review is the Rural Hospital Health Cooperative
and Bonnie Laffey is the contact at (608) 643-2343.
The web site is http://www.rwhc.com/services/peerreview.aspx or http://www.rwhc.com and click on "Services" and then "Peer Review Services."