Critical Access Hospital CoP 2022: Pt. 3 of 5
Critical Access Hospital Conditions of Participation 2022: Pt. 3 of 5
Tuesday, February 8 | 9:00 AM - 11:00 AM CST
Offered Through Partnership with Georgia Hospital Association
OVERVIEW:
This five-part webinar series will cover the entire Critical Access Hospital (CAH) Conditions of Participation (CoP) manual from the Centers for Medicare & Medicaid Services (CMS). It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual, especially ones that apply to their department. Attendees will learn how to do a gap analysis to increase compliance, and we will discuss common areas of deficiency. The fifth session will also delve more deeply into the Quality Assurance & Performance Improvement (QAPI) worksheet and program requirements.
There were over 700 pages of regulations for Critical Access Hospitals (CAHs) in 2020. In addition to several important memos regarding COVID-19, there were changes to discharge planning, antibiotic stewardship program, access to medical records, infection control, QAPI, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis,
changes to the swing bed requirements, life safety code and facility services, and revised emergency preparedness requirements.
LEARNING OBJECTIVES:
At the conclusion of part 3, participants should be able to:
- 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 proper insulin pens usage
- 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 what CMS requires for discharge planning
At the conclusion of part 4, 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
At the conclusion of part 5, participants should be able to:
- Recall that CMS has a worksheet on QAPI
- Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
- Discuss the rewritten the QAPI requirements CMS implemented for CAHs
- Discuss the Governing Board’s ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
- Recall that hospitals are receiving a high number of deficiencies in QAPI
TARGET AUDIENCE:
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.
SPEAKER:
Laura A. Dixon, BS, JD, RN, CPHRM is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states.
Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided consultation to the physicians and staff for the western United States.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing. She is licensed to practice law in Colorado and California.
This speaker has no real or perceived conflicts of interest that relate to this presentation.