Conditions of Participation

The standards for REHs closely align with the current CAH CoPs in most cases, while accounting for the uniqueness of REHs and statutory requirements. In most instances, the REH policies also closely align with the current hospital and ambulatory surgical center standards, such as the policies for outpatient service requirements and the life safety code (LSC), respectively. The REH CoPs establish a full range of health and safety standards specific to governance, services offered, staffing, physical environment, and emergency preparedness.

Specific requirements include:

• REHs must have a clinician on-call at all times and available on-site within 30 or 60 minutes depending on if the facility is located in a frontier area.
• The REH emergency department must be staffed 24 hours per day and seven days per week by an individual competent in the skills needed to address emergency medical care, and this individual must be able to receive patients and activate the appropriate medical resources to meet the care needed by the patient.
• REHs must develop, implement, and maintain an effective, ongoing, REH-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program, and it must address outcome indicators related to staffing.
• The annual per-patient average length of stay cannot exceed 24 hours, in accordance with the statute, and the time calculation begins with the registration, check-in, or triage of the patient and ends with the discharge of the patient from the REH (which occurs when the physician or other appropriate clinician has signed the discharge order or at the time the outpatient service is completed and documented in the medical record).
• REHs must have an infection prevention and control and antibiotic stewardship program that adhere to nationally recognized guidelines.