Critical Access Hospital CMS Conditions of Participation 2020: Ensuring Compliance

Sep. 2, 9, 16 & 23

Noon-2 p.m. Central

Reduced pricing! Member rate, $65 per webinar. Non-member rate, $115 per webinar.

This series will review the changes in the CMS CoP manual and highlight the information most impacting Critical Access Hospitals, these include reviewing the changes and tag numbers in the QAPI standards, which have been completely rewritten for critical access hospitals.

The annual favorite is back in a four-part format and 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.  

Learning Objectives:

  • 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; and
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.
  • 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  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use;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; and
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.
  • 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; and
  • Discuss that CMS requires that a plan of care be done.
  • 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; and
  • Recall that hospitals must have a visitation policy and patients must be informed.

Target Audience:

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.


Sue Dill Calloway, RN, J.D., president, Patient Safety and Healthcare Education and Consulting
Sue Dill Calloway, RN, J.D., has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and also the chief learning officer for the Emergency Medicine Patient Safety Foundation. Prior to her current role, she was the director of hospital patient safety for The Doctors' Company and OHIC Insurance Company. She has led many educational programs for nurses, physicians, and other health care providers. Dill has authored more than 100 books and numerous articles. A frequent speaker, Dill is well known across the country in the area of health care law, risk management, and patient safety.