Critical Access Hospital CMS Conditions of Participation 2019: Ensuring Compliance

Sep. 4, 11, 18 & 25

Noon-2 p.m. Central

This educational activity is jointly provided by AXIS Medical Education and The Texas Hospital Association.

The annual favorite is back in a four-part format to review recent changes in each section of the Critical Access Hospital CMS Conditions of Participation manual. The webinars 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. The October 2018 changes rewrote all of the swing bed regulations. They also now contain the swing bed interpretive guidelines and survey procedures which are under Appendix PP. Changes were made to the survey process and procedures. This program will also discuss the proposed changes in 2019 in the Hospital Improvement Rule, which includes the requirements to have an antibiotic stewardship program, medical records, QAPI, nursing, and more.  

Learning Objectives:

  • Describe that CMS requires that the board must enter into a written agreement if the hospital wants to enter into a telemedicine service;
  • 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.
  • 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  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use;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.
  • Recall that many sections of the manual were rewritten in 2015 including nursing, drugs and biologicals, pharmacy, and infection control;
  • Recall that CMS has an infection control worksheet that may be helpful to CAHs;
  • Discuss that insulin pens can be used on one patient only;
  • 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.
  • 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.

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.


Sue Dill Calloway, RN, J.D., president, Patient Safety and Healthcare Education and Consulting
Sue Dill Calloway, RN, J.D., has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and also the chief learning officer for the Emergency Medicine Patient Safety Foundation. Prior to her current role, she was the director of hospital patient safety for The Doctors' Company and OHIC Insurance Company. She has led many educational programs for nurses, physicians, and other health care providers. Dill has authored more than 100 books and numerous articles. A frequent speaker, Dill is well known across the country in the area of health care law, risk management, and patient safety.