Critical Access Hospital CMS Conditions Of Participation 2022: Ensuring Compliance, 4-parts, May 18, 25, June 1 and 8, Noon-2 p.m. CST


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 increased number of deficiencies. Common deficiencies and how to avoid them will be discussed.  

Important Registration Information

Please register using the PDF form or contact the THA Service Center at 512/465-1057 or to register. Our online registration system is currently unavailable as we update the website.

Part 1

  • Describe that CMS requires the Board enter into a written agreement for telemedicine services
  • Recall CMS 3 worksheets which a CAH can utilize as a self-assessment tool to enhance compliance
  • Describe that CMS has a list of emergency drugs and equipment every CAN must have
  • Recall that all CAH must comply with EMTALA requirements
  • Recall that the average length of stay in a CAH should not exceed 96 hours on annual basis

Part 2

  • Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy
  • Describe the benefits and requirements for CAH to utilize Compounding Pharmacies
  • Recall the requirements for security and storage of medications, medication carts and anesthesia carts
  • Discuss the requirement for dietary to meet the nutritional needs of patients and requirements of a dietitian

Part 3

  • 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

Part 4

  • 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
  • Recall that CMS patient rights are in Swing Beds section

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.


Lena Browning, MHA, RNC-NIC, CSHA, Consultant, Nash Healthcare 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. 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. She is a true pioneer in leadership development and coaching for excellence in healthcare accreditation.

Susan Seeley, MSN, RN, NEA-BC Senior Consultant, Nash Healthcare Consulting
Susan Seeley has over 40 years of experience in the healthcare industry both as a nurse leader and as a clinical consultant with a focus on patient care services and regulatory compliance. As a consultant, Susan is experienced in conducting Centers for Medicare and Medicaid Services (CMS) and Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC) Healthcare Facilities Accreditation Program (HFAP) mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education.

She has prepared organizations for continuous survey readiness by implementing ongoing teams to continue regulatory compliance after mock surveys and assists organizations with writing and implementing successful Plans of Corrections for EMTALA and other CMS and Joint Commission survey deficiencies. Susan has also performed assessments of quality programs and reviews of clinical operations, the structure and function of medical staff committees and implementation of peer review quality plans.

Prior to becoming a consultant, Susan spent 19 years as Chief Nursing Officer at Florida rural hospital while working part time for the parent company as a clinical consultant for their 200+ hospitals. In this role, she also had several other departments she was responsible for including Infection Prevention, Pharmacy Services, Nutritional Services and Quality.

Critical Access Hospital CMS Conditions Of Participation 2022: Ensuring Compliance

Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 2.0 contact hours each.

Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

AXIS Contact Information 
For information about the accreditation of this program please contact AXIS at

Disclosure of Conflicts of Interest
AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity.

AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty, Lena Browning and Susan Seeley reported no relevant financial relationships or relationships she has with ineligible companies of any amount during the past 24 months.

The directors, planners, managers, and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

Name of Planner/ManagerReported Financial Relationship
Shirley LaVergne, CMPNothing to disclose
Lindsay ThompsonNothing to disclose
Holly M. Hampe, D.Sc., RN, MHA, MRMNothing to disclose
Dee Morgillo, MEd, MT (ASCP), CHCPNothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:

  • Attend/participate in the educational activity and review all course materials.
  • Complete the CE Declaration form online by 11:59 pm ET July 8, 2022. Instructions will be provided at the conclusion of each Webinar. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation. 
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.