RCAH Regulatory and Compliance Resources

Father holding son's hand in hospital bed

The Washington State Office of Rural Health is not the part of the Washington State Department of Health that regulates hospitals. We do not perform hospital inspections or licensing surveys and do not have access to your survey results.

We do maintain relationships with regulatory teams to be able to support you with maintaining hospital inspections or licensing survey requirements and staying informed of regulatory changes.

 

Critical Access Hospital Designation

Critical Access Hospitals (CAHs) represent a distinct provider type with their own Medicare Conditions of Participation (CoP) as well as a distinct payment method. The CoPs for CAHs are listed in the “Code of Federal Regulations” at 42 CFR 485 subpart F.

The following providers may be eligible to become CAHs:

  • Currently participating Medicare hospitals;
  • Hospitals that ceased operations on or after November 29, 1989; or
  • Health clinics or centers (as defined by the state) that previously operated as a hospital before being downsized to a health clinic or center.

If your facility is exploring the possibility of CAH designation, your first step is to formally reach out to our State Office of Rural Health. We are more than happy to connect you with appropriate resources, discuss feasibility, and navigate the formal process with you.

Federal Regulations for CAHs:

Contact the Rural Health Office if you are interested in learning more about designation conversion or would like to begin taking formal steps.

 

CAH Mock Survey Program

2024-2025 was our first year providing mock licensing inspection surveys for critical access hospitals. The Mock Survey Program is designed specifically for Critical Access Hospitals and offers a comprehensive assessment of your operations. We contract with a team of experienced health care professionals that will conduct an in-depth review, simulating a real survey. 

The survey identifies areas where your hospital excels and highlights opportunities for improvement including:

  • Review of clinical and clinical support departments
  • Review of Swing Bed processes
  • Review of patient medical records using the tracer methodology
  • Review of selected policies and procedures
  • System tracers including:
    • Human Resources and Employee Health
    • Infection Prevention and High-Level Disinfection and Sterilization
    • Laboratory Waive Testing and Blood Administration
    • Restraints and Ligature Risk
    • Medication Management
    • Medical Staff Credentialing and Privileging
    • Quality Assurance and Performance Improvement

Key Benefits of Participating

  • In-depth review of regulatory compliance: A thorough evaluation of your hospital’s compliance with Conditions of Participation or deemed status regulations. 
  • Preparation for official surveys: Help ensure that your hospital is fully prepared for your official regulatory survey, reducing the risk of citations and penalties.
  • Actionable insights: Provide actionable feedback and recommendations for improvements that can be implemented immediately to enhance patient care and meet regulatory requirements.
  • Customized assistance: Survey tailored to the needs of your hospital, addressing the unique challenges faced by critical access facilities.

Program Details

Duration: The mock survey typically takes 3 days to complete.

Cost: The Washington State Medicare Rural Hospital Flexibility Grant, our Flex program, covers the cost for the execution of the mock survey. Your facility will be responsible for covering travel costs of the mock survey team while at your facility.

Data Sharing: Your individual mock survey results will not be shared with our Flex program unless you choose to do so. Hospitals may choose to share key points when requesting assistance from our Flex program to improve any findings.

The mock survey team will share an aggregated report of overall findings from all participating hospitals both in our state and on a national level with our program to guide funding priorities for our grant work plan.

If you are interested in participating in this program, contact the Rural Health Office.

 

CAH Regulatory and Compliance Series

The Washington State Medicare Rural Hospital Flexibility Grant program has partnered with HealthTech to provide training opportunities designed to support CAH needs surrounding hospital survey readiness. Our program provides financial support for this series, ensuring that you have access to valuable resources, subject matter experts, and training opportunities.

In this educational series, participants learn about the regulatory requirements for critical access hospitals to receive Medicare and Medicaid reimbursement. Key topics include CMS and state regulations, survey readiness, policy review, and human resources requirements.

The series covers nursing department regulations, medication management, infection prevention, antibiotic stewardship, and Quality Assurance Performance Improvement programs. Participants also explore medical staff credentialing, emergency management, and compliance with environment of care and life safety standards.

Please see session recordings below:

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