Critical Access Hospital Conditions of Participation (5 part series)

May 17, 24, June 7, 14 and 21, 2023


Critical Access Hospitals Five-Part Series 2023

Centers for Medicare and Medicaid, Conditions of Participation

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 CAH 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 per webinar
Non-Member: $199 per webinar
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.

CAH Conditions of Participation 2023 – Part 1

Wednesday, May 17, 2023, Noon-2 p.m.

Speaker: Darlene Evans, MSN, RN, CPHQ, NEA-BC, Accreditation Senior Consultant, Nash Consulting

Learning Objectives:

    • Describe that CMS requires 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 the length of stay in the CAH should not exceed 96 hours on an annual average basis.

    • Discuss recommendations to do a gap analysis to ensure compliance with all hospital CoPs.

CAH Conditions of Participation 2023 – Part 2

Wednesday, May 24, 2023, Noon-2 p.m.

Learning Objectives:

  • 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.
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.

CAH Conditions of Participation 2023 – Part 3

Wednesday, June 7, 2023, Noon-2 p.m.

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.

CAH Conditions of Participation 2023 – Part 4

Wednesday, June 14, 2023, Noon-2 p.m.

Learning Objectives:

  • 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.
  • Recall that hospitals must have a visitation policy and patients must be informed.

CAH Conditions of Participation 2023 – Part 5

Wednesday, June 21, 2023, Noon-2 p.m.

Learning Objectives:

  • Discuss CMS Deficiency Date on QAPI
  • Discuss Adverse Event Reporting requirements and what QAPI requires.
  • Review QAPI Conditions of Participation.
  • Discuss systems for and requirements needed to identify medical errors.
  • Review CMS worksheets including discharge planning, infection control and QAPI.
  • Touch on additional resources including the National Quality Forum.


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 Epidemiology (APIC).

Darlene Evans, MSN, RN, CPHQ, NEA-BC, Accreditation Senior Consultant, Nash Consulting

Darlene Evans is a healthcare quality leader with more than 25 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and business development. With her expertise in Centers for Medicare and Medicaid Services, Joint Commission, and Healthcare Facilities Accreditation Program standards and her commitment to education and collaboration, Darlene has a proven track record of helping clients identify opportunities for improvement and achieve sustainable, long-term results. She has also helped lead organizations through projects in areas such as operational effectiveness, infrastructure, staffing and productivity, fiscal stewardship, leadership development, and care delivery.

Darlene was Senior Manager of Clinical Operations, Quality, Safety, and Performance Improvement with Quorum Health Resources. In this role, she provided consultative services to 150 client hospitals, including accreditation, quality, and life safety and environment of care assessments, and the implementation of operational process improvement tools and best practices, as well as other specialty patient quality and safety initiatives.

Previously, Darlene worked with the Joint Commission International as a hospital and ambulatory care accreditation surveyor for healthcare organizations in Turkey, India, Ireland, Saudi Arabia, UAE, and China. In addition to her consulting and surveyor experience, Darlene has served in full-time leadership roles including Chief Nursing Officer, Vice President of Patient Care Services, Assistant Vice President of Nursing Services, and Director of Quality Management and Education.

Darlene earned her Master’s Degree and Bachelor’s Degree in Nursing from Troy State University in Troy, AL. She has also taken courses in business and management and is Lean Six Sigma certified. Darlene is a Registered Nurse, a Certified Professional in Healthcare Quality, and a member of the American College of Healthcare Executives and the National Association for Healthcare Quality.