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Description
2025 was an interesting time for health care providers with Federal and state law changes, updates to Critical Access Hospital regulations, and Acute hospitals interpretative guidelines and survey procedures impacting several areas of Appendix A, respectively. Federal and Appellate court actions on OB emergency care and record requests seemed to change daily.
This webinar will cover the new Interpretive Guidelines for Acute hospitals in five sections, and newly released regulations for Critical Access Hospitals, some of which mirror regulations already present for Acute hospitals. There will also be a brief discussion of the multiple CMS memos that either expired or were rescinded this year. These changes and updates are not reflected in the current manuals, but hospitals must nonetheless comply. Hospitals that accept Medicare and Medicaid payments must comply with these changes for all patients, regardless of the payment source.
Learning Objectives
At the conclusion of part one, participants should be able to:
- Describe the new guidelines for unified and integrated QAPI programs for acute and CAHs
- Discuss the new guidelines for ligature safety in an acute hospital
- Describe the new guidelines and regulations for emergency services to include obstetrical emergencies for Acute and CAHs
- Recall the new obstetrical care guidelines for Acute and Critical Access hospitals.
Outline
ACUTE APPENDIX A UPDATES
MOON
- Part of the Conditions of Participation
Patient Rights
- Care in a safe setting
- Death reporting
Quality Assessment Performance Improvement Program
- New Interpretive Guidelines for Unified and Integrated Programs
- Obstetrical Services and four requirements
Nursing Services
- Requirements for RN in outpatient services
Physical Environment
- Ligature risks
- Emergency power and lighting
- Life Safety Code updates
- Maintenance of alcohol-based hand rubs
- Monitoring when sprinkler systems are down
- Windows and therapeutic/diagnostic facilities
Infection Prevention and Control and ASP
- Guidelines updated
- Leadership’s responsibilities
Discharge Planning
- Tag numbers renumbered and clarified
- Patient evaluation
- Person to develop a plan
- Transfer protocols – new
- PAC services updates
Emergency Services Readiness and Preparedness
- New Tag numbers address readiness, protocols, and training
- Preparedness added when and how exemptions are allowed
Obstetrical Services – New Section
- Organization
- Staffing
- Delivery of services
- Training
Psychiatric Hospitals/Units
- New guidelines for all standards
- Medical records
- Services
- Neurological examination
- Treatment plan
- Progress notes
- Discharge summary
- Staff requirements
- Nursing, Social, and Therapeutic Services
CRITICAL ACCESS NEW REGULATIONS
Location and Off-Campus
- 2-lane roads
Patient Rights
- Notice of rights
- Grievances
- Exercise of Rights
- Privacy and confidentiality
- Restraint or seclusion
- Staff training requirements
- Death reporting
- Visitation
Emergency Services
- Provisions and protocols
- Staff training
- Transfer protocols
Physical Plant and Emergency Preparedness
- Life safety code additions
- Training/testing exemptions for emergency preparedness
- Unified and integrated programs
Provision of Services
- Medical Staff – unified and integrated programs
- Interoperability of clinical records
- Antibiotic Stewardship
- Person qualified
- Reporting illnesses
- Unified and integrated programs
Quality Assessment Performance Improvement
- New OB and QAPI requirements
- Unified and integrated programs
Swing Beds
- Cross-reference to the SNF manual on Patient rights omitted
Obstetrical Services – New Section
- Organization
- Staffing
- Delivery of services
- Training
Expired or Rescinded Memos
Resources
Who Should Attend
- CEOs
- COOs
- CMO
- CNO
- Emergency department manager and physicians
- Compliance director
- Nurse managers/supervisors
- Quality managers
- Risk managers
- Health information management personnel
- Nurses
- Nurse educators
- Surgical supervisor and physicians
- Patient safety officer
- Infection preventionist
- Infection control team members
- Leader of the Antibiotic Stewardship program
- QAPI leaders and staff
Speaker
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado, providing consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director of 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 creating presentations on risk management topics, assessing healthcare facilities, developing programs, and compiling reference materials that complement physician-oriented products.
Before joining COPIC, she served as the Director, of the 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 in 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 over 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.