Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2022 Update- 4 Part Series

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Critical Access Hospital (CAH) Conditions of
ParticipationEnsuring Compliance 2022 Update 4
Part Series
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Speaker Details
Ms. Laura A. Dixon (BS, JD, RN, CPHRM)
Laura A. Dixon served as the Director, Facility
Patient Safety and Risk Management, and
Operations for COPIC from 2014 to 2020. In her
role, Ms. Dixon provided patient safety and risk
management consulting and training to facilities,
practitioners, and staff in multiple states. Such
services included the creation of and
presentations on risk management topics,
assessment of healthcare facilities, and
development of programs and compilation of
reference materials that complement
physician-oriented products. 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
patient safety and risk management consultation
to the physicians and staff for the western
United States.
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Introduction

• Critical Access Hospital CoP Compliance Update
  2022 four-part webinar series will cover the
  entire CAH CoP manual. 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. 
• Critical Access Hospital CoP Compliance Update
  2022 will help CAHs comply with specific CoP
  problem areas, including nursing care plans,
  necessary policies and procedures, medication
  carts and drug storage, informed consent, verbal
  orders, medication administration, protocols,
  standing orders, and emergency preparedness.
  There are many pharmacy standards and
  medication-related sections that overlap, which
  will be covered in detail.

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Detailed Program Outline and Objectives of
Critical Access Hospital CoP Compliance Update
2022
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Part One Critical Access Hospital (CAH) CoP
Compliance Update 2022Introduction, General
Information, Memos, Recent Laws, Safe Injections,
Advance Directives, Emergency Services EMTALA,
and Observation StatusTuesday, January 18, 2022
(0100 PM EST - 0300 PM EST)Duration - 120
Minutes
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Learning Objectives of Part 1

• After part one, participants should be able to
• Describe that CMS requires the Board enter into a
  written agreement for telemedicine services
• Recall CMS 3 worksheets which a CAH can utilize
  as a self-assessment tool to enhance compliance
• Describe that CMS has a list of emergency drugs
  and equipment every CAN must have
• Recall that all CAH must comply with EMTALA
  requirements

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Webinar Agenda of Part 1

• Introduction
• Deficiencies and problematic standards for CAHs
• Survey Protocol
• Regulations and Interpretive Guidelines for CAHs
• Compliance with Federal, State and Local Laws and
  Regulations
• EMTALA obligations

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Part Two Critical Access Hospital (CAH) CoP
Compliance Update 2022Physical Plant
Environment, Emergency Preparedness, Governing
BoardPharmacy and DietaryWednesday, January
19, 2022 (0100 PM EST - 0300 PM EST)Duration
- 120 Minutes
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Learning Objectives of Part 2

• After 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 benefits and requirements for CAH to
  utilize Compounding Pharmacies
• Recall the requirements for security and storage
  of medications, medication carts, and anesthesia
  carts
• Discuss the requirement for dietary to meet the
  nutritional needs of patients and requirements of
  a dietitian  

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Webinar Agenda of Part 2

• Introduction
• Physical Plant and Environment
• Emergency Preparedness
• Organizational Structure and Governing
  Body/Individual
• Staffing and Responsibilities
• Provision of Services
• Pharmacy/ Drugs and Biologicals 
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• Dietary and Nutrition Services

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Part Three Critical Access Hospital (CAH) CoP
Compliance Update 2022Infection Prevention,
Safe Medication, Lab, Provision of Services
Outpatient, Laboratory, Nursing and Discharge
PlanningThursday, January 20, 2022 (0100 PM
EST - 0300 PM EST)Duration - 120 Minutes
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Learning Objectives of Part 3

• 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 that insulin pens can only be used on one
  patient
• Explain that there are three-time frames in which
  to administer medications
• Discuss that CMS requires that a plan of care be
  done

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Webinar Agenda of Part 3

• Introduction
• Infection Prevention and Control
• Provision of services
• Lab Services
• Nursing
• Discharge Planning

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Part Four Critical Access Hospital (CAH) CoP
Compliance Update 2022Radiology, Rehab,
Visitation, Medical Records, QAPIOrgan
Procurement, Swing Beds Friday, January 21,
2022 (0100 PM EST - 0300 PM EST)Duration -
120 Minutes
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Learning Objectives of Part 4

• After part three, participants should be able to
• 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
• Recall that CMS patient rights are in the Swing
  Beds section.

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Webinar Agenda of Part 4

• Introduction
• Radiology
• Rehab
• Visitation
• Medical Records
• Quality Assurance Performance Improvement QAPI
• Organ, Tissue, and Eye Procurement
• Special Requirements for CAH Providers of
  Long-Term Care Services (Swing beds)

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Who Should Attend Critical Access Hospital CoP
Compliance Update 2022

• CEOs
  
• COOs
• CFOs
• Nurse executives
• Accreditation and regulation director
• Nurse managers/supervisors
• Pharmacists
• Quality managers
• Risk managers
• Medication team
• Ethicist
• OR supervisor
• OR staff
• CRNA/anesthesia providers
• Dietician
• Director of Rehab

• Health information management personnel
• Social workers
• Dieticians
• Nurses
• Nurse educators
• Patient safety officer
• Infection preventionist
• Radiology director
• Laboratory director
• Emergency department directors
• Outpatient director
• Radiology staff
• Infection control committee members
• Pharmacists
• Compliance officers

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Here Critical Access Hospital (CAH) Conditions
of ParticipationEnsuring Compliance 2022 Update
4 Part Series
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