Critical Access Hospital (CAH) Conditions of Participation 2025(THA 4.29.25)

Date: April 29, May 1, 6, 8, 13, 15, 20, 22, & 27, 2025
Time: 12:00 pm – 1:00 pm CST (March 27 will be from 12:00 pm - 2:00 pm)
Cost: $645 to NHA members (Per hospital, no charge for additional lines.)
Course Curriculum:
Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This nine-part webinar series will cover the CAH CoP manual. Included is a 2-hour program on Patient Rights – one of the most cited segments of the Manual. The CAH Manual does not include a specific section on Patient Rights as does the Acute manual; but hospitals must provide a safe environment for patients and method to ensure all patient rights are met.
There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control and antibiotic stewardship, QAPI and Swing Bed changes.
This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and drug storage, and informed consent to name a few.
Learning Objectives:
Part 1 - Introduction, General Information, Memos, Distinct Units, Advance Directives, Required Disclosures, Number of Beds, Length of Stay, and Observation Status
• Describe how to find the manual and updates
• Describe what to expect with a survey
• Describe required disclosures for a CAH
• Recall what is included in 25-bed maximum count
• Recall that the average length of stay in a CAH should not exceed 96 hours on annual basis

Part 2 - Patient Rights: Advance Directives, Giving Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, and Visitation, Restraint and Seclusion
• Describe the requirement for a hospital to have a grievance policy and procedure in place
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
• Describe the various patient rights to include providing consent, forming advance directives and visitation rights
• Recall that CMS has restraint standards that hospitals must follow

Part 3 - Emergency Services, Staffing and Responsibilities, Provision of Services, Emergency Procedures and EMTALA
• Describe staffing requirements and supervision
• Recall the required14 emergency department written policies that must be present
• Describe that CMS has a list of emergency drugs and equipment every CAH must have
• Recall that a CAH must comply with EMTALA requirements

Part 4 - Physical Plant & Environment, Emergency Preparedness
• Describe expectations for a safe environment for patient care
• Recall the requirements for equipment maintenance and an alternative management program
• Explain the importance of maintaining ventilation, temperature, and lighting within a CAH
• Describe the mandatory training and exercises for an emergency preparedness plan

Part 5 - Governing Board, Agreements and Contracted Services, QAPI, Discharge Planning
• Describe that CMS requires the Board enter into a written agreement for telemedicine services
• Describe requirements for contract management for a CAH
• Describe the essential elements of a QAPI program and Board responsibilities
• Recall the requirement for when a discharge evaluation must be completed

Part 6 - Pharmacy, Infection Prevention and Control and Antibiotic Stewardship
• Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
• Recall the requirements for security and storage of medications, medication carts and anesthesia carts
• Describe the responsibilities of the infection preventionist
• Describe the responsibilities of the leader of the antibiotic stewardship program

Part 7 - Nursing, Clinical Records
• Discuss nursing service and leadership requirements
• Recall the requirements for medication orders
• Discuss that CMS requires that a plan of care be done
• Recall requirements for contents of clinical records
• Discuss security requirements for clinical records and when “blocking” for access can occur

Part 8 - Radiology, Laboratory, Surgical Services, Anesthesia, Organ Procurement
• Discuss compliance requirements for radiology and laboratory services
• List what must be contained in the operative report
• Discuss the required content for informed consent
• Discuss the requirements for pre-and post-anesthesia assessment
• Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency

Part 9 - Rehab, Dietary, Visitation, Swing Beds
• Recall the requirement for an order for rehabilitation
• Discuss the requirement for dietary to meet the nutritional needs of patients and requirements of a dietitian
• Recall the requirement for nondiscrimination in visitation policies and practices
• Recall that CMS patient rights are in Swing Beds section
• Discuss the reporting requirements for allegations of abuse or neglect of swing bed patients

Who Should Attend:

CEOs, COOs, CFOs, Nurse Executives (CNO), Accreditation and Regulation Director, Nurse Managers, Pharmacists, Pharmacist Compliance Officers, Health information management, Nurses, Nurse Educators, Nursing Supervisors, Quality Managers, Risk Managers, Healthcare Attorneys, Health Information Management Personnel, Social Workers, Patient safety officer, Infection preventionist, Radiology director, Emergency Department Directors, Outpatient Director, Medication Team, Ethicist, Director of Rehab: OT, PT, speech pathology, and audiology, CRNA, Anesthesia providers, Radiology staff, QAPI staff, Policy and Procedure Committee, Dietician, Activities Director of swing bed patients, and Infection Control Committee Members.

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

Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Before joining Kaiser, she served as the director of facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Before joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff of the western United States

As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.