Critical Access Hospital (CAH) Conditions of Participation 2023 – Part 3

 More

The Critical Access Manual has seen multiple changes over the last few years. From all new tag numbers and new requirements for QAPI, to Infection Prevention and Control, and the Antibiotic Stewardship Program, this five-part series will cover the CAN manual and more.  Attendees will learn details about the Conditions of Participation, and what to do and expect when a surveyor arrives at your facility.  This complete series will further help a Critical Access Hospital comply with problem areas including nursing care plans, necessary policies and procedures, medication management, and emergency preparedness.

Registration Pricing

Member: $179
Non-Member: $199
Registration includes unlimited connections per registered facility.

Who should attend:

CEOs, COOs, CFOs, Nurse Executives (CNO), Accreditation and Regulation Director, Nurse Managers, Pharmacists, Pharmacist Compliance Officers, Health information management, Nurses, Nurse Educators, Nursing Supervisors, Quality Managers, Risk Managers, Healthcare Attorneys, Health Information Management Personnel, 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, and Infection Control Committee Members.

Learning Objectives:

  • 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.

Faculty

Lena Browning-Calloway, MHA, BSN, RNC-NIC, CSHA, Nurse Consultant, Nash Consulting

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. Lena has also 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 two 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 Epidemiolo (APIC).