Critical Access Hospital CMS Conditions of Participation 2022 Ensuring Compliance

May 18, 25, June 1 and 8, 2022

Noon-2 p.m. Central

The annual favorite is back in a four-part format and 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.  

Learner Objectives

Part 1

  • 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
  • Recall that the average length of stay in a CAH should not exceed 96 hours on 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 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

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
  • Discuss that CMS requires that a plan of care be done

Part 4

  • 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 Swing Beds section

Target Audience:

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.


Laura Dixon, J.D., RN, president, Healthcare Risk Education and Consulting, LLC

Laura Dixon, J.D., RN has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Healthcare Risk Education and Consulting, LLC in Denver, Colorado, where she provides consultation to clients on CMS regulations, risk and patient safety regulations. She was previously the Director, Patient Safety/Risk Management Facilities and Operations at COPIC. She was responsible for facility program for insureds and also planned and developed the annual Patient Safety/Risk Management Forum. Dixon also spent 14 years with The Doctors Company, Napa, CA; first as the Regional Patient Safety/Risk Manager - Colorado and then as the Director of the Department of Patient Safety, Western Region - Colorado. Among her many accomplishments, she developed and provided patient safety risk management services to over 5,000 existing and potential policyholders in 10 states; researched and developed patient safety risk management education programs; and planned and directed semi-annual regional meetings for western Patient Safety Department members.