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Webinar: Critical Access Hospital (CAH) Conditions of Participation 2020: Ensuring Compliance Part 1
Wednesday, September 09, 2020, 10:00 AM - 12:00 PM EDT
Category: Education

Did you know there are over 600 pages of new regulations for CAHs? Did you know that CMS has changed all the tag numbers and has issued a new CAH manual in 2020? Did you know there are 188 tag number changes in 2020? This is a must attend webinar for every CAH. There are several important memos about COVID-19 that will be discussed.

 Online Registration

Every hospital should be prepared in case a surveyor showed up at your door tomorrow. This four part webinar 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. Hospitals will learn how to do a gap analysis to increase compliance. CMS has changed the website to get the CAH manual and also the email address to ask questions and this information will be provided.

There are many changes in 2020 from the 600 pages of CMS new discharge planning and Hospital Improvement Rules. These address requirements for the antibiotic stewardship program, access to medical records, QAPI, infection control, policy review every two years, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, four changes to the swing bed requirements, and more. CMS   also changed all the CAH tag numbers. There are new changes regarding life safety code and facility services. There are 25 new tag numbers in infection control and antibiotic stewardship and 9 new tag numbers in QAPI. It also added the revised emergency preparedness requirements.

The October 2018 changes rewrote all of the swing bed regulations along with four 2020 changes. They also now contain the swing bed interpretive guidelines and survey procedures which are under Appendix PP.  Changes were made to the survey process and procedures.

This program will also discuss in detail the changes to the new discharge planning standards. CMS will issue interpretive guidelines and survey procedures on these.

CAHs hospitals must comply with the Centers for Medicare & Medicaid Services’ CoP manual for Critical Access Hospitals. The CMS regulations and interpretive guidelines serve as the basis for determining compliance and this manual will be discussed in detail as well as the revised changes.  Attendees will learn details about the CoPs and what to do when a surveyor arrives at your facility.

CMS has issued many important hospital memos including privacy and confidential which is especially important in light of the HIPAA and the substantial penalties seen recently.  Other memos include texting of orders, humidity in the OR and the effects of humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the QAPI program, prevention of Legionella, complaint manual update, OPO contracts, EBOLA, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.

While CMS is not using the infection control worksheet at CAHs at this time, the webinar will discuss why it is important to be aware of what is in this worksheet and to use this as a self assessment tool. There is also a final and revised worksheet on discharge planning and QAPI. There are ten new tag numbers for QAPI.

This seminar will help CAHs comply with specific CoP problem areas, including nursing care plans, legibility requirements, necessary policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness. There are many pharmacy standards and medication-related sections that will be covered in detail. Every tag section in the regulations and interpretive guidelines also will be covered. Attendees will learn details about the CoPs and what to do when a surveyor from arrives at your facility.

Who Should Attend?

CEOs, COOs, CFOs, nurse executives, accreditation and regulation director, nurse managers, pharmacists, quality managers, risk managers, healthcare attorneys, health information management personnel, social workers, dieticians, health information management,  nurses, nurse educators, nursing supervisors, patient safety officer, infection preventionist, radiology director, emergency department directors, outpatient director, medication team, ethicist, director of Rehab (OT, PT, speech pathology, and audiology), OR supervisor, OR staff, CRNA,  anesthesia providers,  dietician, radiology staff, director of health information management, infection preventionist, dietician, activities director of swing bed patients, infection control committee members, pharmacists, and compliance officers.

Detailed Program Outline and Objectives

PART ONE OF FOUR   Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

Objectives - At the conclusion of part one, participants should be able to:

  • Describe that CMS requires that 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 that 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 the hospital CoPs.


  • History
  • Final changes: Discharge planning and the Hospital Improvement Rule
  • Most recent changes
  • New tag numbers in 2020
  • CMS memos
  • Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, texting, revised complaint manual, humidity in the OR, OPO contracts, equipment maintenance, EBOLA, CRE, ligature risks and scopes, glucose meters etc
  • ISMP IV Push Guidelines
  • CAH problematic standards
  • CAH Resources
  • Conditions of participation
  • CMS 3 Worksheets
  • How to find manual, survey memos, and changes
  • CMS websites
  • Copies of documents by surveyor
  • How to locate changes
  • Rehab or Psych distinct unit standards
  • CMS Survey and Certification website
  • Visitation
  • Telemedicine standards

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

Regulations and Interpretive Guidelines for CAHs

  • Swing bed module
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Licensure, Certification or Registration of Personnel
  • Status and Location
  • Location Relative to Other Facilities or Necessary Provider Certification
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality
  • Advanced directives
  • Emergency Services, respiratory policies
  • ED staffing
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Coordination with Emergency Response Systems
  • Number of Beds and Length of Stay
  • Observation, two midnight rule
  • Number of Beds
  • Length of Stay

Contact: Tammy Wells