CAH Standards Review

The PIN is providing a tag by tag review of the State Operations Manual survey tags for CAHs beginning in March 2014.
How we will conduct this review:

  • the PIN will host a monthly conference call, beginning on March 2014, and held the 3rd Tuesday of each month at 3:00 pm until all tags have been reviewed.
  • calls will last roughly one hour each
  • all PIN members are invited to participate
  • it will be an interactive call among the participants, discussing how your organization meets the standard(s) under discussion
  • we will send a reminder each month before the call, indicating which standard of the SOM the discussion will begin with.  Depending on the amount of discussion per tag, we may cover one tag, or several tags, during each session
  • there is no cost to the CAH facility to participate, except your own staff time
  • there is no sign-up required to participate on the calls- simply call in at the date/time indicated when tags of interest to your organization come up for discussion, and skip those that you are less interested in reviewing

CALL NOTES AND RESOURCES

Next Call:
July 21, 2015 at 2:00 pm
Tags 374-380 Transfer & Discharge
Tags 381-386 Resident Behavior and Facility Practices
Tags 388-396 Comprehensive Care Plans
Tags 397-403 Facility Services
Tags 404-408 Dental Services

Tags 345 - 372
Notes

  • Tag C 345 - 349 Organ and Tissue Donation
  • Tag C 349 - 372 Resident Rights for Swing Bed


Tags 330 - 343: April 21, 2015
Notes
CAH Periodic Program Evaluation Tool Kit
CPMC Mid-Level Review Tracking Sheet

  • Tag C 330 - 335 Periodic Evaluation and QA Review
  • Tag C 337 - 343 Quality Assurance

Tags 311 - 326: March 17, 2015
Notes

  • Tag C 311 - Records Retention
  • Tag C 320 - 326 - Surgical Services

Tags 1001 - 1002, 300 - 310: February 17, 2015
Notes
Central MT Medical Center Visitation Policy
Cabinet Peaks Medical Center Visitation Policy
Barrett Hospital and Healthcare Medical Staff Non-Compliance Policy
Broadwater Health Center Chart Completeness Review

  • Tag C 1001-1002 - CAH Patient Visitation Policies
  • Tag C 300-310 - Clinical Records

Tags 294 - 298, 1000: January 13, 2015
Notes

Tags 280 - 293: December 16, 2014
Notes
Contract Review Form (Barrett)

  • Tag C 280 - Policy Review
  • Tag C 281 - 284 - Patient Services
  • Tag 285 - 293 - Arrangements and Agreements

Tags 270 - 279: November 18, 2014
Notes
Guidelines for Medical Management (Barrett)
Illness Log (CMMC)

  • Tag C 270 - 279 Provision of Services: Patient Care Policies

Tags 151 - 192: March 18, 2013 
Notes
Definition of a network hospital

  • Tag C 150 - 170 Compliance w/ Federal, State and Local Laws & Regulations; Status, Location
  • Tag C 191 - 192 Agreements: with Network Hospitals

Tags 192 - 202: April 15, 2014
Notes

  • Tag C 192 - 197 Agreements
  • Tag C 200 - 202 Emergency Services

Tags 202-220: May 20, 2014:
Notes

  • Tag C 202-209 Emergency Services
  • Tag C 210- 212 Number of Beds and Length of Stay

Tags 203 - 230: June 17, 2014
Notes
Monthly Safety Inspections (Beartooth)
Daily Equipment and BioMed Inspection (Beartooth)

  • Tag C 203 - 226 Physical Plant and Environment
  • Tag C 227 - 230 Emergency Procedures

Tags 231 - 261: July 22, 2014
Notes
CoP Reporting Letter from Governor (Barrett)
Reporting Change of Ownership (Barrett)

  • Tag C 231 - 235 Life Safety from Fire
  • Tag C 241 - 244 Organizational Structure
  • Tag C 251 - 268 Staffing and Staff Responsibilities