Critical Access Hospital CMS Conditions of Participation 2021: Ensuring Compliance

May 19, 26, June 2 and 9

Noon-2 p.m. Central

There were over 700 pages of new regulations for CAHs for 2020, including a change to all the tag numbers along with a new CAH manual. Most of the new Tag numbers do not include Interpretive Guidelines or Survey Procedures. This is a must attend webinar for every CAH. There are several important memos about COVID-19 that will be discussed.

There were 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. CMS also changed all the CAH tag numbers. There are new changes regarding life safety code and facility services. There are 25 new tag numbers in infection control and antibiotic stewardship and 10 new tag numbers in QAPI. It also added the revised emergency preparedness requirements

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:

PART 1 OF 4: Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

  • 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.

Part 2 of 4: Pharmacy, Dietary, Maintenance, Board, ED, and Policies

  • 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  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use;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.

Part 3 of 4: 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; and
  • Discuss that CMS requires that a plan of care be done.

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

  • 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.


Laura Dixon, J.D., RN, president, Healthcare Risk Education and Consulting, LLC

Laura Dixon, J.D., RN has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Healthcare Risk Education and Consulting, LLC in Denver, Colorado, where she provides consultation to clients on CMS regulations, risk and patient safety regulations. She was previously the Director, Patient Safety/Risk Management Facilities and Operations at COPIC. She was responsible for facility program for insureds and also planned and developed the annual Patient Safety/Risk Management Forum. Dixon also spent 14 years with The Doctors Company, Napa, CA; first as the Regional Patient Safety/Risk Manager - Colorado and then as the Director of the Department of Patient Safety, Western Region - Colorado. Among her many accomplishments, she developed and provided patient safety risk management services to over 5,000 existing and potential policyholders in 10 states; researched and developed patient safety risk management education programs; and planned and directed semi-annual regional meetings for western Patient Safety Department members.