Can anyone provide me with the verbiage regarding policies at a CAH flowing through a patient care committee, or even point me in the right direction of where I can find this information. I’m wondering if policies have to go through this committee every year, or only initially upon implementation of the policy? Thanks 
Question about Critical Access Hospitals
@Dierdra Hunter Short Answer: Annual Review Required.The followingis a long answer but here you go… The Governing Body of a Critical Access Hospital or individual responsible for the CAH, consistent with the requirement at 485.627(a) must review and approve patient care policies and procedures. The CMS regulations are as follows: 485.635(a)(2) ? patient care policies are developed with the advice of members of the critical access hospital?s (CAH) professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of 485.631(a)(1). 485.635(a)(4) ? patient care policies are reviewed at least annually by the group of professional personnel and reviewed as necessary by the CAH. The CAH?s written policies governing patient care services must be developed with the advice of members of the CAHs professional healthcare staff. This advisory group must include: At least one MD or DO; and One or more physician assistants, nurse practitioners, or clinical nurse specialists, at least one of these non-physician practitioners if these professionals are included in the CAH?s healthcare staff, as permitted at 485.631(a)(1). A CAH with no non-physician practitioners on staff is not required to obtain the services of an outside non-physician practitioner to serve on the advisory group. The advisory group not only makes recommendations for new CAH patient care policies, but is also expected to review the existing patient care policies at leastannuallyand, if it concludes that changes are needed, recommend those changes . Policies must be reviewed and, as applicable, revised more frequently when required , for example, in response to a change in Federal or State regulations to which the CAH is subject. Remember that critical access hospitals must maintain documentation that provides evidence that the advisory group has conducted its reviews and made recommendations concerning patient care policies . Although a CAH?s patient care policies are developed and periodically reviewed with the advice of members of the CAH?s professional healthcare staff,the final decision on the content of the written policies is made by the CAH?s governing body or individual responsible for the CAH, consistent with the requirement at 485.627(a).If recommendations of the advisory group are rejected, the governing body must include in the record of its adoption of the final written policies its rationale for adopting a different policy than that recommended. Ensure that your critical access hospital has documentation showing that the advisory group developed written recommendations on the CAH?s patient care policies for consideration by the CAH?s governing body/responsible individual. A critical access hospital must also be able to show that the advisory group reviewed the CAH?s existing policies at least annually and indicated whether or not it recommended any changes.
Commented by: Cheryl Kirchner