New Hampshire Critical Access Hospitals
Quality Improvement Network

                                 Survey Preparation Tools

Minutes Template
This is a sample minutes template designed to focus on the ACTION and BY WHOM and WHEN sections, with less emphasis (based on limited space) on documenting extensive discussions.

CAH Conditions of Participation Survey Preparation Tracking
This document provides a checklist format of all the requirements contained in Appendix W interpretive guidelines and survey procedures sections. It will allow the CAH to assign accountability by condition and provide a tracking mechanism regarding CAH readiness for the survey. This document is over 100 pages long! Recommended to be used in conjunction with the Medicare/Medicaid Critical Access Hospital Accountability and Status Tracking document.

CAH CoP Survey Preparation Tracking             

CAH Accountability and Status Tracking   

Kitchen/Food Service Observation form        

Medicare/Medicaid Critical Access Hospital Accountability and Status Tracking
This document provides a running list of each condition from Appendix W. It is a tracking document allowing the CAH to list in one location who is accountable, what is the documentation, where the documentation is located and what is the current status of the condition. This will be a useful counterpart to the CAH Conditions of Participation Survey Preparation Tracking document.

Miscellaneous CAH Survey Helpful Tip         

Requested Information at Time of Entry       

List of Information the State of NH Survey Team May Request
This is a list, by content area/department, of materials the State of NH survey team may request upon entry to a CAH for a survey. This will help prepare your organization for the terminology and types of materials that may be requested.
        
Survey Process Questionnaire

Plan of Correction document (11/2004)
This is the Statement of Deficiencies and Plan of Correction Form used by the survey team at the conclusion of a survey. Page 2 includes instructions for how the surveyors are to complete the form.    

General Observations of the Facility (7/95)
The Surveyors may use the questions on this form to focus observations of the facility.

The preparation of materials on this section of the website were financed in part under an Agreement with the State of New Hampshire, Department of Health and Human Services, Division of Public Health Services, with funds provided in part or in whole by the United State Department of Health and Human Services.