New Hampshire Critical Access Hospitals
Quality Improvement Network
                       
CAH Resources - Appendix W

Appendix W CAH Conditions of Participation:
      Interpretive guidelines for Critical Access Hospitals

C-0151   Compliance with Federal Laws and Regulators

C-0153   Licensure of CAH
                       State of NH Licensure Requirements with sample notification letter
                       Posting Requirements  NH RSA Title XI, 151.5.1

C-0205   Blood and Blood Products
                        ARC Blood Transfusion Criteria

C-0211   Number of Beds/Length of Stay      
                       Bed Management Presentation                      
                       Observation Patient Status,  mid-levels       FAQ
                       Newborns                                                 FAQ
                       Observation Bed

C-0241   Governing Body Responsibilities                        FAQ
                        Medical Staff Appointment

C-0242   Disclosure
                       State of NH Licensure Requirements  

C-0243   Person Responsible
                       State of NH Licensure Requirements    

C-0244    Responsibility for Medical Direction      

C-0260    MD/DO Counter Signatures                  
                       S&C 05-32 Physician Oversight of Mid-Levels

C-0272    Policy Advisory Group                            
                       Non-CAH member                                    FAQ
                       Swing Bed Policy List

                       Generic Policy on Policy Management
                       This document is intended to provide a jumpstart to a CAH
                       in developing a policy regarding how the organization manages
                       policies, both new and existing. This is in response to the
                       several requirements in Appendix W, as outlined in the
                       coinciding document Policy Management per Appendix W. 
                       This generic policy is most beneficial when used in conjunction
                       with this document.

                       Policy Management per Appendix W
                       This document reflects the sections in Appendix W that speak
                       to policy development, maintenance and review as it outlines
                       key conditions and requirements.

C-0277   Medication Safety/Adverse Drug Reactions
                      Pediatric Sedation
                      FDA Drug Recalls

C-0278   Infection Control   
                     Sample Antibiogram
                     CMS COP draft revisions (December 2006)
                     NH HFA Compliance with 2005 CDC TB Guidelines Letter
                     NH RSA Title X, Chapter 141-C: Communicable Disease
                     COP Revisions

C-0283   Radiology Services
                     OrderAuthentication - 42 CFR Part 482 Final Rule 11/27/06                      

C-0291   Contracts
                     Sample Contract Template                 

C-0294   Nursing Service
                   Restraints - 42 CFR Part 482 Final Rule 12/8/06  FAQ                                           

C-0307   Medical Records
                      OrderAuthentication - 42 CFR Part 482 Final Rule 11/27/06           

C-0320   Surgical Services
                      History and Physicals - 42 CFR Part 482 Final Rule 11/27/06

C-0322   Anesthesia Assessment
                      Post-Anesthesia Evaluation - 42 CFR Part 482 Final Rule 11/27/06
                      This requirement permits the post-anesthesia evaluation for
                      inpatients to be completed and documents by any individual
                      qualified to administer anesthesia instead of only the individual
                      who administered the anesthesia.

C-0330   QAPI
                     QAPI Annual Report Template  

C-0333   Chart Review
                     Sample Chart Review Tracking Template  

C-0336   Grievance Process
                    General Hospital Interpretive Guidelines C-0336

C-0350   Swing Bed Program                                          FAQ
                    Swing Bed Policy List

C-0378   Timing of Discharge Notice                               FAQ

C-0379   Contents of Discharge Notice                            FAQ

C-0381   Restraints                                                          FAQ
                    42 CFR Part 482 Final Rule 12/8/06                                   

C-0385   Activities                                                           FAQ

C-0388   Resident Assessment                                         FAQ

C-0405   Dental Services                                                 FAQ

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.