RCAH Regulatory and Compliance Resources

Our State Office of Rural Health is not the regulatory arm at the agency and we do not perform hospital surveys and do not have access to your survey results.

Our program does maintain relationships with the survey teams in order to assist your facilities with maintaining survey requirements and staying informed of regulatory changes.

CAH Mock Survey Program

2024-2025 was our first year providing mock 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 will identify areas where your hospital excels and highlight 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 interested in participating in this program, contact the Rural Health Office.

CAH Regulatory and Compliance Series

Our Washington State Medicare Rural Hospital Flexibility (Flex) Grant program is partnering 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 will 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 will cover nursing department regulations, medication management, infection prevention, antibiotic stewardship, and Quality Assurance Performance Improvement (QAPI) programs. Participants will also explore medical staff credentialing, emergency management, and compliance with environment of care and life safety standards.

See our flyer to register for the remaining sessions. We will update with recordings once the series is complete. 

Critical Access Hospital (CAH) Designation

Critical Access Hospitals represent a separate provider type with their own Medicare Conditions of Participation (CoP) as well as a separate 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.

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

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