CMS Conditions of Participation 2022 | Critical Access Hospitals Five-Part Series

Product Id : HLT15
Instructor : Lena Browning

Part- 1 : May 09, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 2 : June 01, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 3 : July 13, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 4 : July 20, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 5 : July 22, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

Jul 22, 2022 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 600 Minutes (5 Part Series)


This five-part webinar series will cover the entire Critical Access Hospital (CAH) Conditions of Participation (CoP) manual from the Centers for Medicare & Medicaid Services (CMS). It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual, especially ones that apply to their department. Attendees will learn how to do a gap analysis to increase compliance, and we will discuss common areas of deficiency.

The fifth session will also delve more deeply into the Quality Assurance & Performance Improvement (QAPI) worksheet and program requirements. There were over 700 pages of regulations for Critical Access Hospitals (CAHs) in 2020. In addition to several important memos regarding COVID-19, there were changes to discharge planning, antibiotic stewardship program, access to medical records, infection control, QAPI, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, changes to the swing bed requirements, life safety code and facility services, and revised emergency preparedness requirements.

Detailed Program Outline:

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

Part 1 of 5 :-  May 09, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre- Recorded)

  • Introduction
  • CAH General Resources
  • CMS Surveyor Training Website
  • Introduction into the Conditions of Participation
  • CMS Hospital Improvement Rule, Discharge Planning, and Recent Changes
  • CMS Memo on Texting
  • CMS Memo on Ligature Risks
  • CMS Memo on Safe Injection Practices
  • ISMP IV Push Medication Guidelines
  • CMS Worksheets – Safe Injection Practices
  • Survey Memos on Infection Control
  • CMS CAH Hospital CoPS
  • Resources and Links

    Part 2 of 5 :-  Pharmacy, Dietary, Maintenance, Board, ED, and Policies ( Pre- Recorded)

    June 01, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

    • Drugs and Biologicals COPS
    • Dietary Standards
    • Why We are Here Today
    • CMS COP Manual
    • Accessing Deficiency Data
    • Physical Plant & Environment
    • Emergency Preparedness
    • Organizational Structure: Governing Body or Responsible Individual
    • Staffing and Responsibilities
    • Provision of Services
    • Resources and Links

    Part 3 of 5 :- Infection Control, Safe Medication, Lab, Patient Services, Outpatient, Nursing and Discharge Planning ( Pre- Recorded)

    July 13, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

    • Why We are Here Today
    • Targeted Infection Control Surveys
    • CDC Vaccine Storage and Handling
    • Final CMS Infection Control Changes and ASP
    • Infection Prevention and Control (IPC) and Antibiotic Stewardship Programs
    • Provision of Services
    • Laboratory Services
    • Nursing
    • Discharge Planning
    • Resources and Links

    Part 4 of 5 :- Radiology, Contracts, Emergency Services, Rehab, Visitation, Medical Records, Surgery, Anesthesia, QAPI, Organs and Swing Beds

    July 18, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre- Recorded)

    • Why We are Here Today
    • Radiology and Nuclear Medicine
    • Rehabilitation
    • Visitation
    • CMS, HIPAA, and OCR Access Medical Records
    • COPS on Medical Records
    • Quality Assurance Performance Improvement
    • Organ, Tissue, and Eye Procurement
    • Swing Beds + 4 Changes
    • Swing Beds Overview Requirements & Rights
    • Resources and Links

    Part 5 of 5 :- QAPI, Medical Staff, Dietary, Radiology, Lab, UR, and Facility Services

    At the conclusion of part Four, participants should be able to:

    Aug 01, 2022 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre- Recorded)

    • Why We are Here Today
    • CMS Deficiency Date on QAPI
    • CMS Survey Memo on QAPI
    • CMS Changes: Hospital Improvement Rule
    • QAPI Conditions of Participation
    • CMS Worksheets
    • Acute Hospitals QAPI
    • Resources and Links

    Who Should Attend:

    • CEOs/COOs/CFOs
    • Nurse Executives (CNO)/Nurse Managers/Nurses/Nurse Educators/Nursing Supervisors
    • Accreditation and Regulation Director
    • Pharmacists/Pharmacist Compliance Officers
    • Health information management/Health Information Management Personnel
    • Quality/Risk Managers
    • Healthcare Attorneys
    • Social Workers
    • Patient safety officer
    • Infection preventionist
    • Radiology director
    • Emergency Department Directors
    • Outpatient Director
    • Medication Team
    • Ethicist
    • Director of Rehab: OT, PT, speech pathology, and audiology
    • CRNA
    • Anesthesia providers
    • Radiology staff
    • QAPI staff
    • Policy and Procedure Committee
    • Dietician
    • Activities Director of swing bed patients
    • Infection Control Committee Member
    Speaker Profile:

    Lena Browning, MHA, BSN, RNC-NIC, CSHA

    Lena Browning is a nurse leader and accreditation specialist with more than twenty-five years of experience in clinical leadership in acute care settings. Throughout her career, she has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence in patient care across healthcare settings. As a Principal Consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team.  Lena has a strong commitment to client relationships and provides support to retainer clients to ensure patient safety and quality of care.  Most recently, Lena has fulfilled 3 Interim positions as Director of Accreditation and was responsible for restructuring accreditation departments and leading organizations in continuous compliance and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey.  Since then, those three organizations have had successful surveys with no condition-level findings.  Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy situations with all organizations getting the IJ lifted, and no condition level findings noted on return surveys.  She is a true pioneer in leadership development and coaching for excellence in healthcare accreditation.

    Prior to consulting, Lena had over 2 decades of experience in Accreditation and Regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired, and facilitated continuous readiness committees, and coached staff and leadership in effective compliance and performance improvement strategies.  Additionally, Lena has extensive experience in Quality and Patient Safety, Performance Improvement, Medical Staff Credentialing and Privileging, Contract Management, and Strategic Planning for Hospitals and Home Care Agencies.    

    Lena earned her Master of Healthcare Administration from the University of Southern Indiana and her Bachelor of Science in Nursing from Murray State University. She is a Registered Nurse Certified in Neonatal Intensive Care, a Certified Specialist in Healthcare Accreditation, and holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post-resuscitation stabilization. Additionally, she is a member of the Association for Professionals in Infection Control and Epidemiology (APIC).

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