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Critical Access Hospitals

Survey protocols and Interpretive Guidelines are established to provide guidance to personnel conducting surveys.  They serve to clarify and/or explain the intent of the regulations and allsurveyors are required to use them in assessing compliance with Federal requirements.  The purpose of the protocols and guidelines is to direct the surveyor’s attention to certain avenues for investigation in preparation for the survey, in conducting the survey, and in evaluation of the survey findings.

The Critical Access Hospital (CAH) survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate.  Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the CAH’s performance or practices. 

CAHs are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment.  The goal of a CAH survey is to determine if the CAH is in compliance with the CoP set forth at 42 CFR Part 485 Subpart F.

Certification of CAH compliance with the CoP is accomplished through observations, interviews, and document/record reviews.  The survey process focuses on a CAH’s performance of organizational and patient-focused functions and processes.  The CAH survey is the means used to assess compliance with Federal health, safety, and quality standards that will assure that the beneficiary receives safe, quality care and services.

The Interpretive Guidelines include three parts:

  • The first part contains the survey tag number. 
  • The second part contains the wording of the regulation. 
  • The third part contains guidance to surveyors, including additional survey procedures and probes.