CMS Critical Access Hospital CoPs
Revised Critical Access Hospital (CAH) Conditions of Participation 2019:
Ensuring Compliance
AXIS Medical Education designates this continuing nursing education activity for 8.5 contact hours.
MS Nursing Home Administrator Board designates this continuing education activity for 1.0 contact hour.
Every hospital should be prepared in case a surveyor shows up at your door tomorrow. This day and a half live program 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.
This program will discuss the changes made in October of 2018. The swing bed regulations were completely rewritten. The manual also made changes to the survey protocol and process.
The program will discuss the proposed changes in 2019 in the Hospital Improvement Rule which will have a major impact on critical access hospitals. This includes the requirements to have an antibiotic stewardship program, medical records, QAPI, nursing, and more. The proposed 2019 discharge planning standards will also be covered which will also have a major impact on critical access hospitals.
The proposed 2019 changes to promote efficiency and transparency and burden reduction will be covered. This includes removing cross-references to requirements for long term care facilities that do not apply because of the short amount of time patients are in swing-beds. This includes the requirements related to dentists, activities director and more. It would change reviewing policies every year to every two years. It would remove the section on disclosure of people with financial interests.
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.
Did you know that about a third of the CMS critical access manual has been rewritten on April 7, 2015? Revisions have been made to the section on nursing, drugs and biologicals, pharmacy, dietary, infection control, lab, radiology, contracted services and adding the rehab section, IV medication, safe opioid use and blood, eligibility to be a CAH, and addition of a CNS availability for on call to respond to the emergency department. It has also been updated four times since then. It will be updated in 2019 to include the texting requirements. This all day program will include information on the entire manual.
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 humidity in the OR, Effects of Humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the QAPI program, texting, prevention of Legionella, complaint manual update, OPO contracts, EBOLA, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.
This program will discuss the CMS three worksheets. While CMS will not be using the infection control worksheet at CAHs, this program will discuss why it is important to be aware of what is in this worksheet. 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, 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.
WEDNESDAY, November 20, 2019
1:00 p.m. Registration
1:30 p.m. – 2:45 p.m. CMS CAH Conditions of Participation for facilities- PART 1
2:45 p.m. – 3:00 p.m. BREAK
3:00 p.m. – 4:30 p.m. CMS CAH Conditions of Participation for facilities- PART 1 (continued)
THURSDAY, November 21, 2019
8:00 – 8:30 a.m. Registration
8:30 a.m.- 10:00 a.m. CMS CAH Conditions of Participation for facilities- PART 2
10:00 a.m. – 10:15 a.m. BREAK
10:15 a.m. – 12:00 p.m. CMS CAH Conditions of Participation for facilities- PART 2 (continued)
Noon – 12:30 p.m. Lunch (provided)
12:30 p.m. – 3:00 p.m. CMS CAH Conditions of Participation for facilities- PART 3
3:00 p.m. Evaluation/Adjournment