Webinar Overview:

Critical Access Hospitals must comply with the Center for Medicare and Medicaid Conditions of Participation if they accept Medicare and Medicaid reimbursement. The hospital must comply with these 206 page standards for all patients and not just Medicare or Medicaid patient. CMS issues interpretive guidelines that serve as the basis for determining hospital compliance.

This seminar will help hospitals comply with specific CMS-CoP problem areas including restraints, nursing care plans, legibility requirements, verbal orders, history and physicals, needed policies and procedures, nursing medication carts, drug storage, medication administration and emergency preparedness. Attendees will learn details about the CoPs and what to do when a CMS or Department of Health surveyor arrives at your facility.

Target Audience:

• 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
• Nurses
• Nurse Educators
• 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
• Anesthesia Providers
• Activities Director of swing bed patients
• Infection Control and Compliance Officers

Webinar Objectives:

• Describe the survey procedure related to CAH CMS-CoPs such as off site preparation, entrance activities, information gathering, document review, exit conference and post survey activities
• Discuss that CMS has a list of emergency drugs 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
• Recall that hospitals must have a visitation policy and patients must be informed

Webinar Outline:

• Introduction
  • History
  • CAH problematic standards
  • CAH Resources
  • Conditions of participation
  • CMS websites
  • Copies of documents by surveyor
  • How to locate changes
  • Rehab or Psych distinct unit standards
  • CMS Survey and Certification website
  • Visitation new regulation
  • Proposed QIO and state agency notification
  • Final telemedicine standards
  • Survey Protocol
• Introduction
  • Tasks in the Survey Protocol
  • Survey Team
  • Task 1 - Off-Site Survey Preparation
  • Task 2 - Entrance Activities
  • Task 3 - Information Gathering/Investigation
  • Task 4 - Preliminary Decision Making and Analysis of Findings
  • Task 5 - Exit Conference
  • Task 6 - Post-Survey Activities
• 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 in a Rural Area or Treatment as Rural
  • 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 Assurance
  • Emergency Services, respiratory policies
  • ED staffing
  • EMTALA
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Coordination with Emergency Response Systems
  • Number of Beds and Length of Stay
  • Physical Plant and Environment
  • Disposal of trash
  • Storage of drugs
  • Physical environment
  • Construction
  • Maintenance
  • Emergency Procedures
  • Life Safety from Fire
  • Emergency fuel and water
  • Emergency preparedness plan
  • LSC waivers
  • Fire inspections