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
Both CMS and TJC changed the annual review requirement for CAH’s in November 2019 to reduce the paperwork burden in healthcare under the Omnibus Burden Reduction (Conditions of Participation) Final Rule CMS-3346-F Now they’ve backed off to every 2 years for review. See below: (If you want to see the original, I copied it directly from the Federal Register ) " 485.635 Condition of participation: Provision of services. (a)Standard: Patient care policies. (1)The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. (2)The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or morephysicianassistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of 485.631(a)(1). (3)The policies include the following: (i)A description of the services the CAH furnishes, including those furnished through agreement or arrangement. (ii)Policies and procedures for emergency medical services. (iii)Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/orpatientreferral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. (iv)Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storageareathat is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available forpatientuse. (v)Procedures for reporting adverse drug reactions anderrorsin the administration of drugs. (vi)Procedures that ensure that the nutritional needs ofinpatientsare met in accordance with recognized dietary practices. Allpatientdiets, including therapeutic diets, must be ordered by the practitioner responsible for the care of thepatientsor by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of 483.25(i)of this chapter is met with respect toinpatientsreceiving post CAHSNFcare. (vii)[Reserved] (viii)Policies and procedures that address the post-acute care needs ofpatientsreceiving CAH services. (4) These policies are reviewed at least biennially by the group of professional personnel required underparagraph (a)(2)of this section and updated as necessary by the CAH." TJC - If you look at the TJC standards, LD.04.01.07 - “The critical access hospital has policies and procedures that guide and support patient care, treatment, and services.” EP# 7: The critical access hospital’s policies are reviewed at least every two years by the group of professional personnel required under LD.04.01.07, EP 6, and reviewed as necessary by the critical access hospital.
Commented by: Cheryl Postlewaite