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Critical Access Hospital Conditions of Participation Audioconference Series
Register for this audioconference series online:
Program Description:
Staying fully informed on changes to the Medicare and Medicaid Conditions of Participation (CoP) is critical to keeping your Critical Access Hospital in compliance. There have been major changes to the interpretive guidelines that the Centers for Medicare & Medicaid Services (CMS) uses to determine hospital compliance. This three-part program will cover all sections in the 198 pages of regulations.
The curriculum will focus on specific problem areas, including: restraints, nursing care plans, eligibility requirements, needed policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration and emergency preparedness.
The series also will look at the extensive standards related to medication management and pharmacy and will discuss new regulations on distance from next hospital and proposed new regulations for 2008.
Every Tag section in the regulations and interpretive guidelines will be covered, and faculty will discuss performing a gap analysis to confirm your hospital's compliance. You'll also learn what to do when a CMS or Texas Department of State Health Services surveyor arrives at your facility. If there is one program that staff should attend this year, this is it.
Session 1
October 7, 2008
Time: 9:30-11 a.m. Central Time
Survey protocol and 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 in a Rural Area or Treatment as Rural; 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; EMTALA; Equipment, Supplies, and Medication; Blood and Blood Products; Staffing/Personnel; Coordination with Emergency Response Systems; Number of Beds; Length of Stay; Physical Plant and Environment; Disposal of Trash; Storage of Drugs; Physical Environment; Construction; Maintenance; Emergency Procedures; Life Safety from Fire; Emergency Fuel and Water; Emergency Preparedness Plan; LSC Waivers; Organizational Structure; Governing Body or Responsible Individual; Disclosure; Staffing and Staff Responsibilities; Responsibilities of the Doctor of Medicine or Osteopathy; Physician Supervision, PA, NP and CNS Responsibilities; Provision of Services; Patient Care Policies; Guidelines for Medical Management; Direct Services.
Learning Objectives:
- Describe the survey procedure related to CAH CMS-CoP.
- Discuss the CMS list of emergency drugs required for every CAH.
- Recall 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.
Session 2
October 14, 2008
Time: 9:30-11 a.m. Central Time
Regulations and Interpretive Guidelines for CAHs
Services Provided through Agreements or Arrangements; Nursing Services; Drug and biologicals; Pharmacy; 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; 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; Investigating and controlling infections; Healthcare associated infections; Infection control policies; Infection control websites; Infection control orientation for new employees; Role of leaders in infection control; Infection control officer; Dietary policies; Dietary compliance; Qualified dietician; Dietary support staff; Direct services; Outpatient department; Outpatient director; Rehab services; PT; OT; audiology and speech pathology; Rehab treatment plan; Required rehab policies; Lab services; Radiology services; Radiology staff; Scope of radiology services; Radiology Policies required; Emergency procedures; Contracted services; Nursing care; Observation of med passes/nursing care; Nursing care plans; RN for each patient; RN supervising care; Drugs and IVs; Verbal orders; Verbal order policy; Culture of questioning.
Learning Objectives:
- Explain the responsibilities of the pharmacists in supervising the activities of the pharmacy.
- Describe the requirements for CAH that ensure outdated drugs are not available for patient use.
- Recall the medication cart requirement for security, including storage.
- Discuss the requirement to have "do not use abbreviations," including the review of sound-alike/look-alike drugs.
Session 3
October 21, 2008
Time: 9:30-11 a.m. Central Time
Regulations and Interpretive Guidelines for CAHs
Medical Records; Records System; Informed consent; History and physicals; Discharge summaries; Response to treatment; Confidentiality of medical records; Retention of medical records; Protection of Record Information; Surgical Services; Surgery policies; PACU; OR register; Operative report; Surveyor in the OR; Surgical privileges; Designation of Qualified Practitioners; Anesthesia services; Anesthetic Risk and Evaluation; Administration of Anesthesia; Discharge; Quality assurance (quality improvement); Hospital associated infections; State Exemption; Periodic Evaluation and Quality Assurance Review; Periodic Evaluation; Quality Assurance; Organ, Tissue and Eye Procurement; Definition of imminent death; Tissue and eye bank; Family notification; Organ donation.
Learning Objectives:
-
Explain the informed consent elements required by CMS.
- Describe the requirements for "History & Physical" 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 agency when a patient expires.
- Name some of the patient rights that are afforded to patients in swing beds.
Faculty
Sue Dill Calloway, RN, MSN, JD, Director, Hospital Risk Management, OHIC Insurance Co./The Doctors' Company
Sue Dill Calloway has been a nurse attorney and medical-legal consultant for more than 25 years. She has presented numerous educational programs for nurses, physicians, and other health care professionals on topics such as nursing law, patient safety, pain management, The Joint Commission, CMS, and HIPAA.
The views expressed by the speaker do not necessarily reflect the policies or opinions or the Wisconsin Hospital Association.
Registration Information
Fee
Per Session Fee: $295 for one phone line per site
Entire Series: $750 for one phone line per site
Please register only one name per connection.
Additional phone lines will be billed at $295.00 each.
How the Audioconference Will Work
Dial-in instructions, on-line login instructions and any other reference materials will be emailed to each registrant approximately three days prior to the conference. If you do not receive them by this date, please email lgeishirt@wha.org.
It is the responsibility of the registrant to access presentation materials prior to the day of the event. If your e-mail address changes, you do not receive an e-mail with instructions from WHA, or if you are unable to open presentation materials, please contact Lisa Geishirt at WHA two days prior to the event to allow time to address the issue.
Substitution, Transfer and Cancellation Policy
Cancellations received in writing up to five business days prior to an event will be given a full refund less a $50 processing fee. No refunds will be given for cancellations received less than five business days prior and day-of-program no-shows. Substitutions are accepted.
Register for this audioconference series online:
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