CMS looks to tweak Medicare conditions of participation for critical access hospitals

July 7, 2022 4:49 pm

In addition to establishing regulations for the new rural emergency hospital (REH) provider category, a recently issued proposed rule includes a few new conditions of participation (CoPs) for critical access hospitals (CAHs).

Primary roads

Several changes stem from a review conducted by CMS regarding distance and location criteria for CAHs.

Specifically, CMS proposes to clarify the definition of primary road in the context of the CoPs. Regulations have required that CAHs be at least a 35-mile drive from the nearest hospital (or other CAH) — or at least a 15-mile drive if the only available roads are considered “secondary” or are in mountainous terrain.

The new proposal establishes that the 35-mile standard applies to the distance from a hospital or another CAH for drives that take place on “primary roads,” defined as roads that are part of the national or interstate highway systems or are a U.S. numbered highway. The proposal expands the definition to include nonfederal highways that are numbered and have at least two lanes each way.

“We are interested in feedback on whether the definition of primary roads should include numbered federal highways with two or more lanes, similar to the description of numbered state highways, and exclude numbered federal highways with only one lane in each direction,” CMS states.

Certification reviews for CAHs would be streamlined. If no new hospitals or CAHs have been established within 50 miles of the CAH being reviewed, recertification would happen immediately. If there are any new hospitals in the radius, additional review would incorporate the 35-mile standard and definition of primary road.

“Those CAHs that do not meet the regulatory distance and location requirements at the time of review would be identified as noncompliant and may face enforcement actions,” CMS states.

“We recognize the impact of these criteria on rural communities and we aim to minimize any disruption to CAHs based on these requirements,” the agency adds.

Patients’ rights

CMS proposes to implement regulations protecting the rights of patients who receive care at a CAH. While the requirements mirror those for patients who receive care at hospitals in general, some mandates — including around the use of restraints and seclusion — “are less prescriptive,” allowing CAHs to “develop policies and procedures based on the scope of services they provide and patient populations they serve.”

Specific patient rights to be formalized include:

  • Notice of rights
  • Exercise of rights
  • Privacy, safety and confidentiality of patient records
  • Use of restraints and seclusion, including staff training and requirements
  • Death reporting requirements
  • Patient visitation rights

“We are specifically soliciting comments on the appropriateness of the patient’s rights requirements proposed for restraint and seclusion, the potential need to require standards that are more stringent to address patient protections, and the feasibility of implementing such requirements in rural communities,” CMS wrote, echoing language regarding a similar proposal for REHs.

System-focused provisions

Several proposals could alleviate administrative burden for CAHs that are part of a larger system.

CMS proposes to allow for a “unified and integrated medical staff shared by multiple hospitals, CAHs and REHs within a healthcare system,” with staff members voting on whether to participate in or opt out of such a structure.

CAHs that are part of a health system also could participate in unified and integrated infection prevention and control and antibiotic stewardship programs if permitted by state and local laws and if certain program requirements are met. For example, each CAH would have to demonstrate that the unified programs account for “each member CAH’s unique circumstances and any significant differences in patient populations and services offered in each CAH.”

Similar provisions would apply to the mandatory quality assessment and performance improvement program.

Comment period

Some of the provisions in the proposed rule about REH and CAH CoPs are subject to change based on stakeholder feedback. Comments are due by Aug. 29 and may be submitted via the portal at


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