Webinar Overview:

In order to receive payment, Critical Access Hospitals (CAH) must comply with the Centers for Medicare and Medicaid (CMS) Conditions of Participation (CoP). CMS issues interpretive guidelines that serve as the basis for determining hospital compliance with the CoPs, and there have been major changes. This program will cover all sections in the 198-page regulations.This seminar will help hospitals comply with specific CMS-CoP problem areas, including: restraints, nursing care plans, legibility requirements, needed policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration and emergency preparedness. There are an extensive number of standards related to medication management and pharmacy. This program will discuss new regulations on distance from next hospital and proposed new regulations for 2008.

Every Tag section in the regulations and interpretive guidelines will be covered. Attendees will learn details about the CoPs and what to do when a CMS or Department of Health surveyor arrives at your facility. If there is one program that staff should attend this year, it is this program. It is essential that hospitals do a gap analysis to confirm compliance with these regulations.

Target Audience:

• CEO
• COO
• CFOs
• Nurse Executives
• Nurse Managers
• Risk Managers
• Pharmacists
• Quality Managers
• PI director
• Director of Accreditation
• Healthcare Attorneys
• Health Information Management Personnel
• Social Workers
• Dieticians
• Consumer Advocate
• Radiology Director
• Emergency Department Directors
• Outpatient Director
• Ethicist
• Eirector of Rehab (OT, PT, speech pathology, and audiology)
• OR supervisor
• Activities Director of swing bed patients
• Infection Control
• Nurse Educator
• Medication Management Team
• Compliance Officers

Webinar Objectives:

• Describe the survey procedure and tasks related to CAH CMS Conditions of Participation
• Recall CAH regulations and interpretive guidelines, including what equipment and supplies a CAH must have

Webinar Outline:

• Introduction
• History
• Conditions of Participation and CMS websites
• Copies of documents by surveyor
• Survey Protocol
  • 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
• Swing bed module
• Compliance with Federal, State and Local Laws and Regulation
  • 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
  • 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
  • Organizational Structure
  • Governing Body or Responsible Individual
  • Disclosure
• Staffing and Staff Responsibilities
  • Responsibilities of the Doctor of Medicine or Osteopathy
  • Physician Supervision, PA, NP and CNS Responsibilities
  • Provision of Services
  • Patient Care Policies
  • Guidelines for Medical Management
  • Direct Services

Contact Hours:

Upon attending this course you will receive a 2.4 Contact Hour Attendance Certificate. There is usually a reciprocal agreement between state associations to allow these to count for each state. If you have any questions, please ask your state association.