Revised Critical Access HealthcarConditions of Participation

Did you know that about a third of the CMS critical access manual has been rewritten on April 7, 2015? It has also been updated four times since then. The most current manual was December 2016. It will be updated in 2018 to include the texting requirements. This includes rewriting 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. This all day program will include information on the entire manual.

There also many proposed changes including rewriting the discharge planning standards. Proposed changes also include the proposed Hospital Improvement rule which will require an antibiotic stewardship program and changes in infection control, nursing, medical records, QAPI and more. The New regulations should be out in 2018.

CAHs hospitals must comply with the Centers for Medicare & Medicaid Services’ CoP 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 both the new and proposed changes.  Attendees will learn details about the CoPs and what to do when a surveyor arrives at your facility. Every section on the CAH hospital manual will be covered in this day and an half program. 

Revised changes were made to direct services required, policies, outpatient, rehab, radiology, services required, equipment maintenance, qualified personnel, radiology records, emergency services, radiology safety, required lab tests and more.

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, Legionella, texting orders, effects of humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the QAPI program, complaint manual update, OPO contracts, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and deficiencies for CAHs.

 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. 

The MS Nursing Home Board of Administrators has approved 8.5 CEUs for this program.  

AXIS Medical Education, Inc. has approved 8.5 CEUs for Nursing.  In order to receive the credits, all attendees will be required to register through a portal following the educational session. 

Program Outline


Objectives - At the conclusion of part one, participants should be able to:
Describe the CMS requires the board must enter into a written agreement if the hospital wants to enter into a  telemedicine services
Discuss that CMS has a list of emergency drugs and emergency equipment 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 

Proposed changes for 2018
Most changes since inception of CAH program
CMS memos
Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, luer misconnections,  revised  complaint manual, humidity in the OR, OPO contracts, equipment maintenance, etc.
CAH problematic standards
CAH Resources
Conditions of participation
How to find manual, survey memos, and changes
CMS websites
Copies of documents by surveyor
How to locate changes
Rehab or Psych distinct unit standards
CMS Survey and Certification website
Telemedicine standards

Survey Protocol
Tasks in the Survey Protocol
Survey Team

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 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
Equipment, Supplies, and Medication
Blood and Blood Products
Coordination with Emergency Response Systems
Number of Beds and Length of Stay
Observation, two midnight rule
Number of Beds
Length of Stay
Physical Plant and Environment
Disposal of trash
Storage of drugs
Physical environment
Construction and equipment
Emergency Procedures
Life Safety from Fire
Emergency fuel and water
Emergency preparedness plan 2016
LSC waivers
Fire inspections 
Board section
Physician responsibilities
Physician supervision
Transfer of patient
Patient admissions
Patient care policies
Medical management
Discrimination and section 1557 requirements

Part 2 of 3

Objectives - At the conclusion of part two, participants should be able to:

Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use.
Recall the requirements for  security and storage of medications, medication carts and anesthesia carts, 
Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs. 

Regulations and Interpretive Guidelines for CAHs

Direct Services
Services Provided through Agreements or Arrangements
Nursing Services
Drug and biologicals
o Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, definition of medication error, adverse event, indicator or trigger drugs

Inspections/staff interviews
Dispensing of drugs
Pharmacist responsibilities
Staffing in pharmacy
Pharmacy policies and procedures 
Medication therapy monitoring
Pharmacy USP 797 regulations
Emergency medicine kits
Drug storage
Nursing med carts/anesthesia carts
Outdated drugs
Survey of pharmacy
Reporting ADR and medication errors
Near misses/good catches
High alert medication
Definition of medication error required
Trigger/indicator drugs
Monitoring medication errors
Medication alerts
Standard of care for medications
Websites and additional resources
Required pharmacy P&P
Do not use abbreviations
Sound alike/look alike drugs
Non-punitive policies

Infection control and proposed changes in 2018
Antibiotic stewardship program
PI must be qualified
2018 proposed changes: 
Investigating and controlling infections
Following national recognized standards and guidelines
Healthcare associated infections
Four challenges in infection control; MDRO, ambulatory care, communicable diseases and bioterrorism
Infection control websites
Infection control orientation new employees
Surveillance, sanitary environment, and mitigation of risks
Role of leaders in infection control
Infection control officer
Requirement for antibiotic stewardship program

Safe Medication
Preparation and administration
10 CDC Safe Injection Practices
CMS IC worksheet and safe injections
Single and multi-dose vials
Fingerstick devices, scopes, glucometers, insulin pens

Dietary and Nutrition Services and 2018 proposed change
Dietary policies
C&P to order diet
Meeting patient needs, diet order, follow recognized dietary practices
Dietary compliance
Qualified dietician
Dietary support staff
Assessment of patients and order

Outpatient Services and proposed 2018 changes
Outpatient department
Outpatient director
Board and MS action 

Rehab section 

Lab services

Many  changes
Radiology services
Radiology staff
Scope of radiology services
Radiology policies required

Contracted Services

Emergency procedures

Nursing and proposed changes in 2018
Nursing care
Observation of med passes/nursing care
Changes in observation guidelines
Nursing care plans
RN for each patient
RN supervising care
Drugs and IVs
Timing of medications
High alert drugs
Safe opioid use
Sedation scales
Blood and blood products
Verbal orders
Verbal order policy
Culture of questioning
Medication passes
Nursing care plan


Part 3 of 3

Objectives - At the conclusion of part three, 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.

Medical Records and changes in 2018
Medical record standards
Texting of orders 
Identification of author
Access to medical records
Inpatient and outpatient requirements for medical records
Records System
Informed consent
List of procedures required for consent
Medical necessity and the RACs (recovery audit contractors)
History and physicals
Discharge summaries
Preventing unnecessary readmissions
Response to treatment
Confidentiality of medical records
Retention of medical records
Protection of Record Information

Surgical Services
Surgery policies required
OR register
Operative report
Surveyor in the OR
Surgical privileges
Designation of Qualified Practitioners

Anesthesia services
Anesthetic Risk and Evaluation
Administration of Anesthesia
Pre-anesthesia evaluation
Post-anesthesia evaluation
PI required
Healthcare-associated infections
State Exemption of CRNAs
Periodic Evaluation

Organ, Tissue and Eye Procurement
Definition of imminent death
Tissue and eye bank
Family notification
Organ donation

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)
SNF Services
Resident Rights
Exercise of Rights
Notice of Rights and Services
Free Choice
Privacy and Confidentiality
Access and Visitation Rights
Personal Property
Married Couples
Admission, Transfer and Discharge Rights
Transfer and Discharge
Payment of care
Content of notice
Resident Behavior and Facility Practices
Restraints, Abuse 
Staff Treatment of Residents
Hiring of employees
Social Services
Resident Assessment
Comprehensive Care Plans
Discharge Summary
Provision of Services
Websites for CAH
CAH resources

Who Should Attend?
Anyone with direct patient care who works in a critical access hospital should attend this program. This includes CEOs, COOs, CFOs, nurse executives (CNO), accreditation and regulation director, nurse managers, pharmacists, quality managers, risk managers, healthcare attorneys, health information management personnel, social workers, dieticians, health information management,  nurses, nurse educators, nursing supervisors, 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, OR staff, CRNA,  anesthesia providers,  dietician, radiology staff, director of health information management, infection preventionist, activities director of swing bed patients, infection control committee members, pharmacists, and compliance officers.


Sue Dill Calloway, RN, AD, BA, BSN, MSN, JD,  CPHRM, CCMSCP  Attorney at Law is currently the a Medical-Legal Consultant and President of Patient Safety and Healthcare Consulting and Education. She is also the past chief learning officer and a current board member for the Emergency Medicine Patient Safety Foundation. She has been employed in the nursing profession for more than 30 years.  Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN,  MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus.  She is a member of many professional organizations. She has authored over 102 books and has published many articles. She is a frequent lecturer on healthcare issues.
7/24/2018 1:00 PM - 7/25/2018 3:00 PM
United States


Tuesday, 24 July 2018

7/24/2018 1:00 PM - 7/25/2018 3:00 PM
7/24/2018 1:00 PM
7/24/2018 1:00 PM - 7/25/2018 3:00 PM
7/24/2018 1:00 PM
7/24/2018 1:00 PM - 7/25/2018 3:00 PM
7/24/2018 1:00 PM

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