Critical Access Hospital Conditions of Participation 2020: Ensuring Compliance - Recorded Webinar Series

December 07, 2020
8:00 AM-8:00 AM

Wisconsin Hospital Association


Program Description

Every hospital should be prepared in case a surveyor showed up at your door tomorrow. This four-part webinar will cover the entire CAH CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that applies to their department.  Hospitals have seen a significant increase in survey activity by CMS along with an increase number of deficiencies. Common deficiencies and how to avoid them will be discussed. Hospitals will learn how to do a gap analysis to increase compliance.
There are many changes in 2020 from the 600 pages of CMS new discharge planning and Hospital Improvement Rules. These address requirements for the antibiotic stewardship program, access to medical records, QAPI, infection control, policy review every two years, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, four changes to the swing bed requirements, and more.

Program Objectives

Part 1

  • Describe that CMS requires that the board must enter into a written agreement if the hospital wants to enter into a telemedicine contract;
  • 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; and
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.
Part 2
  • 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  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use;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; and
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.
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;
  • Describe that an order is needed to allow the patient to self-administer medications;
  • Explain that there are three time frames in which to administer medications; and
  • Discuss that CMS requires that a plan of care be done.
Part 4
  • 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; and
  • Recall that hospitals must have a visitation policy and patients must be informed.

Who Should Attend

All hospital staff involved with CMS discharge planning and Hospital Improvement Rules.