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 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. 

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.

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  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use.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

About the Speaker(s)

Speaker: Nash Healthcare Consulting