Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the CAH’s performance or practices.ĬAHs are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment. The Critical Access Hospital (CAH) survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. The purpose of the protocols and guidelines is to direct the surveyor’s attention to certain avenues for investigation in preparation for the survey, in conducting the survey, and in evaluation of the survey findings. They serve to clarify and/or explain the intent of the regulations and allsurveyors are required to use them in assessing compliance with Federal requirements. Survey protocols and Interpretive Guidelines are established to provide guidance to personnel conducting surveys.
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