Critical Access Hospital CMS Conditions Of Participation 2022: Ensuring Compliance, Part 3


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.  

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

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.