Critical Access Hospital (CAH) Conditions of Participation 2020: Ensuring Compliance- 4 Part Webinar Series

Product Id : HE257
Instructor : Sue Dill Calloway

Part- 1 : March 10th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 2 : March 17th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Part- 3 : March 24th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Part- 4 : April 07th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

Apr 07, 2020

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 4 Part webinar series that covers the entire manual

Every hospital should be prepared in case a surveyor showed up at your door tomorrow. This four part webinar will cover the entire CAH CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that applies to their department.  Hospitals have seen a significant increase in survey activity by CMS along with an increase number of deficiencies. Common deficiencies and how to avoid them will be discussed. Hospitals will learn how to do a gap analysis to increase compliance.

There are many changes in 2020 from the 600 pages of CMS new discharge planning and Hospital Improvement Rules. These address requirements for the antibiotic stewardship program, access to medical records, QAPI, infection control, policy review every two years, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, four changes to the swing bed requirements, and more.

The October 2018 changes rewrote all of the swing bed regulations. They also now contain the swing bed interpretive guidelines and survey procedures which are under Appendix PP.  Changes were made to the survey process and procedures.

This program will also discuss in detail the changes to the discharge planning standards. CMS will issue interpretive guidelines on these.

CAHs hospitals must comply with the Centers for Medicare & Medicaid Services’ CoP manual for Critical Access Hospitals. The CMS regulations and interpretive guidelines serve as the basis for determining compliance and this manual will be discussed in detail as well as the revised changes.  Attendees will learn details about the CoPs and what to do when a surveyor arrives at your facility. 

CMS has issued many important hospital memos including privacy and confidential which is especially important in light of the HIPAA and the substantial penalties seen recently.  Other memos include texting of orders, humidity in the OR and the effects of humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the QAPI program, prevention of Legionella, complaint manual update, OPO contracts, EBOLA, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.

Did you know that about a third of the CMS critical access manual was rewritten effective April 7, 2015 and three changes in 2016? This includes rewriting the section on nursing, drugs and biologicals, pharmacy, dietary, infection control, lab, radiology, contracted services, rehab section, IV medication, safe opioid use and blood, eligibility to be a CAH, and the availability for on call providers to respond to the emergency department. 

While CMS is not using the infection control worksheet at CAHs at this time, the webinar will discuss why it is important to be aware of what is in this worksheet and to use this as a self assessment tool. There is also a final and revised worksheet on discharge planning and QAPI.

This seminar will help CAHs comply with specific CoP problem areas, including nursing care plans, legibility requirements, necessary policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness. There are many pharmacy standards and medication-related sections that will be covered in detail. Every tag section in the regulations and interpretive guidelines also will be covered. Attendees will learn details about the CoPs and what to do when a surveyor from arrives at your facility. 

Detailed Program Outline and Objectives

PART ONE OF FOUR :  March 10th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes (Pre- Recorded)

Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

Objectives - At the conclusion of part one, participants should be able to:

  • Describe that CMS requires that the board must enter into a written agreement if the hospital wants to enter into a  telemedicine contract
  • Discuss that CMS has a list of emergency drugs and emergency equipment that every CAH must have.
  • Recall that the length of stay in the CAH should not exceed 96 hours on an annual average basis.
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.


  • History
  • Final changes: Discharge planning and the Hospital Improvement Rule
  • Most recent changes 
  • CMS memos
  • Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, texting, revised complaint manual, humidity in the OR, OPO contracts, equipment maintenance, EBOLA, CRE, ligature risks and scopes, glucose meters etc
  • ISMP IV Push Guidelines
  • CAH problematic standards
  • CAH Resources
  • Conditions of participation
  • CMS 3 Worksheets
  • How to find manual, survey memos, and changes
  • CMS websites
  • Copies of documents by surveyor
  • How to locate changes
  • Rehab or Psych distinct unit standards
  • CMS Survey and Certification website
  • Visitation 
  • Telemedicine standards

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

Regulations and Interpretive Guidelines for CAHs

  • Swing bed module
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Licensure, Certification or Registration of Personnel
  • Status and Location
  • Location Relative to Other Facilities or Necessary Provider Certification
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality 
  • Advanced directives
  • Emergency Services, respiratory policies
  • ED staffing
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Coordination with Emergency Response Systems
  • Number of Beds and Length of Stay
  • Observation, two midnight rule
  • Number of Beds
  • Length of Stay

Part 2 of 4: March 17th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

Pharmacy, Dietary, Maintenance, Board, ED, and Policies

Objectives - At the conclusion of part two, participants should be able to:

  • Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use.
  • Recall the requirements for  security and storage of medications, medication carts and anesthesia carts, 
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs. 
  • Physical Plant and Environment
  • Disposal of trash
  • Storage of drugs
  • Physical environment
  • Construction and equipment
  • Maintenance
  • Emergency Procedures-moved to new appendix Z
  • Life Safety from Fire
  • LSC waivers
  • Fire inspections 
  • Board section
  • Staffing
  • Physician responsibilities
  • Physician supervision
  • Transfer of patient
  • Patient admissions
  • Patient care policies
  • Medical management

Regulations and Interpretive Guidelines for CAHs

  • Direct Services
  • Services Provided through Agreements or Arrangements
  • Drug and biologicals
    • Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, definition of medication error, adverse event, indicator or trigger drugs


  • Inspections/staff interviews
  • Dispensing of drugs
  • Pharmacist responsibilities
  • Staffing in pharmacy
  • Pharmacy policies and procedures 
  • Medication therapy monitoring
  • Pharmacy USP 797 regulations
  • Emergency medicine kits
  • Drug storage
  • Nursing med carts/anesthesia carts
  • Outdated drugs
  • Survey of pharmacy
  • Reporting ADR and medication errors
  • Near misses/good catches
  • High alert medication
  • Definition of medication error required
  • Trigger/indicator drugs
  • Monitoring medication errors
  • Medication alerts
  • Standard of care for medications
  • Websites and additional resources
  • Required pharmacy P&P
  • Do not use abbreviations
  • Sound alike/look alike drugs
  • Non-punitive policies

Dietary and Nutrition Services

  • Final change
  • Dietary policies
  • C&P to order diet
  • Meeting patient needs, diet order, follow recognized dietary practices
  • Dietary compliance
  • Qualified dietician
  • Dietary support staff
  • Assessment of patients and order

Part 3 of 4: March 24th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

Infection Control, Safe Medication, Lab, Patient Services, Outpatient, Nursing and Discharge Planning


  • Recall that the infection preventionist must be appointed by the board
  • Recall that CMS has an infection control worksheet that may be helpful to CAHs
  • Discuss that insulin pens can only be used on one patient 
  • Describe that an order is needed to allow the patient to self administer medications
  • Explain that there are three time frames in which to administer medications
  • Discuss that CMS requires that a plan of care be done

Infection control

  • Final changes to infection control
    • Antibiotic stewardship requirements
  • Infection control worksheet
  • CDC and FDA health update
  • Investigating and controlling infections
  • Following national recognized standards and guidelines
  • Healthcare associated infections
  • Four challenges in infection control; MDRO, ambulatory care, communicable diseases and bioterrorism
  • Infection control websites
  • Infection control orientation new employees
  • Surveillance, sanitary environment, and mitigation of risks
  • Role of leaders in infection control
  • Infection control officer

Safe Medication

  • Preparation and administration
  • 10 CDC Safe Injection Practices
  • CMS IC worksheet and safe injections
  • Single and multi-dose vials
  • Fingerstick devices, scopes, glucometers, insulin pens

Patient Services

  • Diagnostic and therapeutic services
  • Supplies

Outpatient Services

  • Outpatient department
  • Outpatient director
  • Final changes 
  • Board and MS action 



  • Nursing care
  • Final changes
  • Observation of med passes/nursing care
  • Changes in observation guidelines
  • Nursing care plans
  • RN for each patient
  • RN supervising care
  • Drugs and IVs
  • Timing of medications
  • High alert drugs
  • Safe opioid use
  • Sedation scales
  • IV medications
  • Blood and blood products
  • Verbal orders
  • Verbal order policy
  • Culture of questioning
  • Medication passes
  • Nursing care plan

Part 4 of 4: April 07th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

Radiology, Contracts, Emergency Services, Rehab, Visitation, Medical Records, Surgery, Anesthesia, QAPI, Organs and Swing Beds

Objectives - At the conclusion of part three, participants should be able to:

  • Explain the informed consent elements required by CMS,
  • Describe the requirements for history and physicals for CAH,
  • List what must be contained in the operative report,
  • Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency when a patient expires,
  • Recall that CMS has many patient rights that are afforded to patients in swing beds.
  • Recall that hospitals must have a visitation policy and patients must be informed 


  • Many  changes
  • Radiology services
  • Radiology staff
  • Scope of radiology services
  • Radiology policies required

Contracted Services

Emergency procedures


  • Written copy to patient and document
  • Patient advocate
  • When patient is incapacitated
  • P&P required
  • Staff education required

Rehab section 

  • Order
  • Plan of care requirements

Medical Records

  • Final changes 
  • Timely access to medical records
  • OCR now fining hospitals if access is not timely
  • Medical record standards
  • Identification of author
  • Inpatient and outpatient requirements for medical records
  • Records System
  • Informed consent
  • List of procedures required for consent
  • Medical necessity and the RACs (recovery audit contractors)
  • History and physicals
  • Discharge summaries
  • Preventing unnecessary readmissions
  • Response to treatment
  • Confidentiality of medical records
  • Retention of medical records
  • Protection of Record Information

Surgical Services

  • Surgery policies required
  • PACU
  • OR register
  • Operative report
  • Surveyor in the OR
  • Surgical privileges
  • Designation of Qualified Practitioners

Anesthesia services

  • Anesthetic Risk and Evaluation
  • Administration of Anesthesia
  • Pre-anesthesia evaluation
  • Post-anesthesia evaluation
  • Discharge
  • PI required
  • Healthcare-associated infections
  • State Exemption of CRNAs
  • Periodic Evaluation

Organ, Tissue and Eye Procurement

  • Definition of imminent death
  • Tissue and eye bank
  • Family notification
  • Organ donation

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)

  • Rewritten and four changes in 2020
  • Eligibility
  • Payment
  • SNF Services
  • Resident Rights
  • Exercise of Rights
  • Notice of Rights and Services
  • Free Choice
  • Privacy and Confidentiality
  • Mail
  • Access and Visitation Rights
  • Personal Property
  • Married Couples
  • Admission, Transfer and Discharge Rights
  • Transfer and Discharge
  • Payment of care
  • Content of notice
  • Resident Behavior and Facility Practices
  • Restraints, Abuse 
  • Staff Treatment of Residents
  • Hiring of employees
  • Activities 
  • Social Services
  • Dental requirements 
  • Resident Assessment
  • Comprehensive Care Plans
  • Discharge Summary
  • Nutrition
  • Provision of Services
  • Websites for CAH
  • CAH resources

Who Should Attend?

  • CEOs, COOs, CFOs
  • Nurse executives,nurse managers,nurses, nurse educators, nursing supervisors
  • Accreditation and regulation director
  • Pharmacists
  • Quality managers
  • Risk managers
  • Healthcare attorneys, health information management personnel
  • Social workers
  • Health information management
  • Patient safety officer
  • Infection preventionist
  • Radiology director
  • Emergency department directors
  • Outpatient director
  • Medication team
  • Ethicist
  • Director of Rehab (OT, PT, speech pathology, and audiology)
  • OR supervisor, OR staff, CRNA,
  • Anesthesia providers,
  • Activities director of swing bed patients, infection control committee members, pharmacists, and compliance officers.
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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