Critical Access Hospital Conditions of Participation
Five-Part Series, Part 5 of 5
(Registration fee is per each session)

       Part 5: Tuesday, Feb. 14 | 9:00 A.M. - 11:00 A.M. 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). This program offers an excellent opportunity to educate every department in your hospital on all the CMS manual sections. The Critical Access Manual has seen multiple changes over the last few years. This series will supplement efforts to comply with challenging areas, including nursing care plans, necessary policies and procedures, medication management, and emergency preparedness. The series will also cover pharmacy standards, medication-related sections, and tag sections in the regulations and interpretive guidelines. Finally, attendees will learn what to do when a surveyor arrives at their facilities.

LEARNING OBJECTIVES:
At the conclusion of this session, participants should be able to:

Part Five:
-Discuss CMS Deficiency Date on QAPI.
-Describe Adverse Event Reporting requirements and what QAPI requires.
-Define the QAPI Conditions of Participation.
-Recite systems for identifying medical errors.
-Review CMS worksheets, including discharge planning, infection control and QAPI.
-Indicate additional resources, including the National Quality Forum.

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.

SPEAKERS:
Lena Browning, MHA, BSN, RNC-NIC, CSHA
Nash Healthcare Consulting

Lena Browning is a nurse leader and accreditation specialist with more than 25 years of experience in clinical leadership in acute care settings. As a principal consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled three interim positions as director of accreditation and was responsible for restructuring accreditation departments and leading organizations in compliance. Additionally, Lena has successfully coached numerous
organizations through Immediate Jeopardy (IJ) situations with all organizations getting the IJ lifted and no condition level findings noted on return surveys.

Prior to consulting, Lena had over two decades of experience in accreditation and regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in compliance and performance improvement strategies.

Lena earned a Master of Healthcare Administration from the University of Southern Indiana and a Bachelor of Science in Nursing from Murray State University. She holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn
resuscitation and post resuscitation stabilization. She is also a member of the Association for Professionals in Infection Control and Epidemiology (APIC).


Susan Seeley, RN, MSN, NEA-BC
Nash Healthcare Consulting

Susan Seeley has over 40 years of experience in the health care industry, both as a nurse leader and as a clinical consultant with a focus on patient care services and regulatory compliance. She is experienced in conducting mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education. Susan has helped organizations achieve continuous survey readiness and assists organizations with writing and implementing successful Plans of Corrections for survey deficiencies. She has also assessed quality programs, clinical operations, the structure and function of medical staff committees, and the implementation of peer review quality plans.

Prior to becoming a consultant, Susan spent 19 years as the chief nursing officer for a rural Florida hospital while working part time for the parent company as a clinical consultant for their more than 200 hospitals. She earned her Master of Science in Nursing Administration and her Bachelor of Science in Nursing from Barry University in Miami Shores, Florida. She is a registered nurse and holds an Advanced Nurse Administrator certification through the American Nurses Association.

These speakers have no real or perceived conflicts of interest that relate to this presentation.