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

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Description

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).

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

Speaker Profile:

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