Critical Access Hospital (CAH) Conditions of Participation 2020: Ensuring Compliance- 4 Part Webinar Series

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 increasing 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.

There are many changes in 2020 from the 600 pages of CMS's 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.

The October 2018 changes rewrote all of the swing bed regulations. 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 discharge planning standards. CMS will issue interpretive guidelines 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 confidentiality 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.

Did you know that about a third of the CMS critical access manual was rewritten effective April 7, 2015, and three changes in 2016? This includes rewriting the section on nursing, drugs and biologicals, pharmacy, dietary, infection control, lab, radiology, contracted services, rehab section, IV medication, safe opioid use and blood, eligibility to be a CAH, and the availability for on-call providers to respond to the emergency department. 

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.

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, the 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 arrives at your facility. 

Part 1 of 4- Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

Monday, March 09, 2020, 01:00 PM EST - 03:00 PM EST, 120 Minutes

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.

Part 2 of 4- Pharmacy, Dietary, Maintenance, Board, ED, and Policies

Monday, March 16, 2020, 01:00 PM EST - 03:00 PM EST, 120 Minutes

At the conclusion of part two, participants should be able to:

• Explain the responsibilities of the pharmacists that including 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. 

Part 3 of 4- Infection Control, Safe Medication, Lab, Patient Services, Outpatient, Nursing, and Discharge Planning

Monday, March 23, 2020, 01:00 PM EST - 03:00 PM EST, 120 Minutes

• 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

Part 4 of 4 Radiology, Contracts, Emergency Services, Rehab, Visitation, Medical Records, Surgery, Anesthesia, QAPI, Organs, and Swing Beds

Monday, March 30, 2020, 01:00 PM EST - 03:00 PM EST, 120 Minutes

At the conclusion of part three, participants should be able to:

• 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 

• 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
• Compliance Officers