This is part 1 of a 5 part series. Register here for the entire series. (Part 1 is on Jan. 13, Part 2 is on Jan. 20, Part 3 is on Jan. 27, Part 4 is on Feb. 3 and Part 5 is on Feb. 10.)

Critical Access Hospitals (CAH) must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) located in Appendix W in the manual. This five-part webinar series will cover the majority of the CAH CoPs manual. The regulations and interpretive guidelines serve as the basis for determining compliance.

There were multiple changes and new regulations for CAHs in 2020, and new United States Department of Health & Human Services (HHS) regulations on patient rights and obstetrical care in 2025. However, most of the new tag numbers do not include interpretive guidelines or survey procedures. The most recent major changes were additions to the regulations from HHS for patient rights, additions for integrated systems and emergency services, specifically
related to obstetrical care.

This series will help CAHs comply with specific CoPs challenges, such as nursing care plans, necessary policies and procedures, drug storage, informed consent, and medication administration.

Part 1

• Describe that CMS requires the Board to enter into a written agreement for telemedicine services.
• Explain that CMS has a list of emergency drugs and equipment every CAH must have.
• Discuss that all CAHs must comply with EMTALA requirements.
• Recall that the average length of stay in a CAH should not exceed 96 hours on an annual basis. 
  

Part 2

• Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
• Describe the benefits and requirements for CAHs to utilize Compounding Pharmacies.
• Recall the requirements for security and storage of medications, medication carts, and anesthesia carts.
• Discuss the requirements for dietary to meet the nutritional needs of patients and requirements of a dietitian. 
  

Part 3

• Recall that the infection preventionist must be appointed by the board.
• Describe responsibilities of the board toward the infection prevention and ASP program.
• Explain the three-time frames in which to administer medications.
• Discuss that CMS requires that a plan of care be done. 
  

Part 4

• Describe the requirements for history and physicals for CAHs.
• List what must be contained in the operative report.
• Discuss what must be included and demonstrated in a QAPI program.
• Recall that CMS patient rights are in the Swing Beds section.
• Describe the new requirements for obstetrical services.

Part 5

• Recall that CMS recently added Patient Rights to the CoPs for CAHs.
• Explain that CMS has restraint standards that hospitals must follow.
• Describe that a hospital must have a grievance policy and procedure in place.
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
• Describe visitation requirements including policies and permitted limitations.

Speaker: Laura Dixon, BS, JD, RN, CPHRM

Click here for a fax/email registration form.