Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2024

April 24, May 1, 8, and 30, 2024


Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This four-part webinar will cover the entire CAH CoP manual. The regulations and interpretive guidelines serve as the basis for determining compliance.

There were multiple changes and new regulations for CAHs in 2020, including a change to all the tag numbers. Most of the new Tag numbers do not include Interpretive Guidelines or Survey Procedures. Other changes included twenty-five new tag numbers in infection prevention and control and antibiotic stewardship and ten new tag numbers in QAPI. As for Swing Bed changes – the regulations are limited to Appendix W, but the interpretive guidelines and survey procedures are in Appendix PP.

This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication carts and drug storage, informed consent, and medication administration to name a few.

Registration Pricing

Member: $175 per webinar
Non-Member: $225 per webinar
Registration includes unlimited connections per registered facility.

Register via PDF

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.

Continuing Education

Continuing Medical Education
This educational activity is jointly provided by AXIS Medical Education and Texas Hospital Association.
The Texas Hospital Association is applying for approval from the following accrediting organizations for the Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2024 Webinar Series.

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.

Credit Designation for Physicians
AXIS Medical Education designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™ each. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Click here for more continuing medical education information.

American College of Healthcare Executives
By attending the Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2024 Webinar Series offered by Texas Hospital Association participants may earn up to 2.0 ACHE Qualified Education Hours each toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

CAH Conditions of Participation 2024 – Part 1

Wednesday, April 24, 2024, Noon-2 p.m.

Part One of Four: Introduction, General Information, Memos, Recent Laws, Safe Injections, Advance Directives, Emergency Services & EMTALA, and Observation Status

Learning Objectives:

  • 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.

CAH Conditions of Participation 2024 – Part 2

Wednesday, May 1, 2024, Noon-2 p.m.

Part Two of Four: Physical Plant & Environment, Emergency Preparedness, Governing Board, Pharmacy and Dietary

Learning Objectives:

  • 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.

CAH Conditions of Participation 2024 – Part 3

Wednesday, May 8, 2024, Noon-2 p.m.

Part Three of Four: Infection Prevention and Control and Antibiotic Stewardship, Safe Medication Administration, Laboratory, Provision of Services: Outpatient, Laboratory, Nursing; and Discharge Planning

Learning Objectives:

  • Recall that the infection preventionist must be appointed by the board.
  • 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 the three-time frames in which to administer medications.
  • Discuss that CMS requires that a plan of care be done.

CAH Conditions of Participation 2024 – Part 4

Thursday, May 30, 2024, Noon-2 p.m.

Part Four of Four: Radiology, Rehab, Visitation, Medical Records, QAPI, Organ Procurement, Swing Beds

Learning Objectives:

  • 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.


Laura A. Dixon, BS, JD, RN, CPHRM, President, Healthcare Risk Education and Consulting, LLC, Denver, CO

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.