QUESTION: Are two Critical Access Hospitals (“CAHs”) allowed to unify their medical staffs?
ANSWER: No. Moreover, as CMS made clear in analyzing the comments it received to the proposed regulations related to unified QAPI and infection control programs in the final version published on September 30, 2019, there are other limits: “One commenter requested that CMS include ‘affiliate’ and CAHs in the unified and integrated QAPI and infection control requirements.” CMS responded:
A CAH must be separately evaluated for its compliance with the CAH CoPs (found at 42 CFR part 485, subpart F), which would not include the requirements included in this section of the rule since these are hospital CoPs. It would not be possible to evaluate the CAH’s compliance as part of an evaluation of a hospital’s compliance. However, this does not preclude a multi-hospital system’s single governing body from also serving as the CAH’s governing body, so long as the governing body clearly identifies the policies and decisions that are applicable to the CAH. 84 Fed. Reg. at 51742.
However, CMS stated that it encourages CAHs to “work with other hospitals or CAHs in their network (if available) for pharmaceutical support” (among other resources) in dealing with the revised antibiotic stewardship requirements. 84 Fed. Reg. at 51783.
The regulations pertaining to CAHs are just a small part of the entire set of regulations.
Join Charlie Chulack and Joshua Hodges for a special audio conference entitled:
“Patients Over Paperwork”?
The New CMS Rules and Their Impact on Your Patients and Policies
October 29, 2019
1:00 to 2:30 pm (ET)
They will discuss the key points in these new regulations, particularly those that affect Medical Staff Rules & Regulations and policies, and revisions you should think about now.
And stay tuned for another special audio conference coming in 2020 on Medical Staff basics for Critical Access Hospitals.