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Critical Access Hospital (CAH) Conditions of Participation 2021: Ensuring Compliance

January 19 @ 8:00 am - 10:00 am MST


Multi-part webinar series that covers the entire manual – Part 1 – Jan. 19; Part 2 – Jan. 26; Part 3 – Feb. 2; Part 4 – Feb. 9; Part 5 – Feb. 16

Access instructions and materials will be emailed to the person completing the order prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.

Due to COVID-19, the registration fee is per hospital and not per connection for this webinar series. A single registration provides multiple lines for employees at your hospital, including a link to view the recording. Please only select a qty. of “1” under Registration and indicate the number of connections requested when completing the Attendee information. This person will be responsible for sharing the access information with others who wish to participate. 

Not sure if you’ll be able to make the live session? Everyone who registers will receive a link to the recording of the webinar to view at your convenience at no additional charge for 60 days post-webinar. 


Part 1-4 | There were over 300 pages of regulations for CAHs in 2020.  Many of the most recent new Tag numbers do not include Interpretive Guidelines or Survey Procedures. There are several important memos about COVID-19 that will be discussed.

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 apply to their department.  Common deficiencies and how to avoid them will be discussed. Hospitals will learn how to do a gap analysis to increase compliance.

There were many changes in 2020 to discharge planning, antibiotic stewardship program, access to medical records, QAPI, infection control, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, changes to the swing bed requirements, life safety code and facility services, infection control plus the revised emergency preparedness requirements.

CMS made updates for COVID-19 reporting that impact hospitals, laboratories, and any nursing home.  Those changes and new requirements impact the duties and responsibilities of hospitals who own or operate a laboratory on site or an affiliated nursing home.

CMS has issued many important hospital memos including privacy and confidentiality, texting of orders, humidity in the OR and the effects of humidity, insulin pens, safe injection practices, reporting to the QAPI program, complaint manual update, contracts, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.

While CMS is not using the infection control worksheet at CAHs at this time, the webinar will discuss why using the worksheet as a self-assessment tool. There is also a final and revised worksheet on discharge planning and QAPI.

Other areas to be covered include: nursing care plans, necessary policies and procedures, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness.

Part 5 | This program is a must attend for critical access hospitals as Critical Access Hospitals have until March 2021 to comply with the QAPI standards.  Additionally, QAPI is one of only three CMS survey sections with a worksheet. The program will discuss the revised CMS hospital QAPI standard and the final changes to QAPI that were effective November 29, 2019.  CMS implemented a similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule and Interpretive Guidelines are still pending. Nonetheless, Critical access hospitals (CAHs) had an additional 18 months to implement the new standards – or until March 2021.  

The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI.  The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys.

Every hospital that accepts Medicare and Medicaid must be in compliance. The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are from CMS. QAPI is an important issue to CMS and an increased area of focus.

This program will discuss the memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, it is estimated that 86% of adverse event are never reported to the hospital’s PI program. Performance improvement is very important to CMS and the hospital conditions of participation require many things to be measured.

PART 1 of 4 Introduction, Memos, Compliance, Agreements, Contracts, Board Duties, Emergency Services, Observation and Physical Environment 

Objectives – At the conclusion of part one, participants should be able to:

  • Describe the method find information on CMS regulations
  • Recall the process to identify common deficiencies cited by CMS
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs
  • Identify changes to CMS CoP manual within the last 3 years 


  • History
  • How to find CMS manuals, survey memos and changes
  • CAH problematic standards
  • CMS websites and CAH Resources
  • Conditions of participation

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

Overview of CAH

  • Basis and scope
  • Rural Health Network
  • Personnel Qualifications
  • Designation and Certification of CAHs 

Agreements and Organization Structure and Board Duties

  • Personnel Qualifications
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Status and Location
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Governing Body
  • Staffing and Responsibilities
  • Physician responsibilities
  • Transfer of patient
  • Patient admissions
  • Medical management
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality
  • Agreements for Telemedicine

Emergency Services and Observation

  • Emergency Services
  • ED staffing
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Number of Beds and Length of Stay
  • Observation, two midnight rule
  • Number of Beds
  • Length of Stay

Physical Environment

  • Physical Plant and Environment
  • Maintenance and equipment
  • Disposal of trash
  • Storage of drugs and biologicals
  • Physical environment and ventilation
  • Construction and equipment
  • Life Safety from Fire
  • LSC waivers
  • Fire inspections
  • Emergency Preparedness – also in Appendix Z

Part 2 of 4 Provision of Services: Nursing, Pharmacy, Dietary, Drugs and Equipment, Surgery, Anesthesia and ED

Objectives – At the conclusion of part two, participants should be able to:

  • 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,
  • Recall the requirements for nursing services and order sets, and protocols.
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.

Provision of Services

  • Patient care policies
  • Review of and required policies
  • Direct Services
  • Services Provided through Agreements or Arrangements
  • Drug and biologicals
    • Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, definition of medication error, adverse event, indicator or trigger drugs 


  • Nursing care
  • Observation of med passes/nursing care
  • Nursing care plans
  • RN – required and supervision
  • Drugs and IVs
  • Medication administration
  • Timing of medications
  • Safe opioid use
  • IVs and Blood
  • Verbal and Standing orders
  • Self-medication administration 


  • Inspections/staff interviews
  • Dispensing of drugs
  • Pharmacist responsibilities
  • Staffing
  • Pharmacy policies and procedures
  • Medication therapy monitoring
  • Emergency medicine kits
  • Drug storage and maintenance
  • Nursing med carts/anesthesia carts
  • Survey of pharmacy
  • Reporting ADR and medication errors
  • High alert medication
  • Definition of medication error required
  • Trigger/indicator drugs
  • Medication alerts
  • Do not use abbreviations
  • Sound alike/look alike drugs

Dietary and Nutrition Services

  • Dietary policies
  • Credentialing and Privileging of Dietician
  • Meeting patient needs, diet order, follow recognized dietary practices
  • Dietary support staff
  • Assessment of patients and order

Surgical Services

  • Surgery policies required
  • Informed consent
  • PACU
  • OR register
  • Operative report
  • Surveyor in the OR
  • Surgical privileges
  • Designation of Qualified Practitioners

Anesthesia services

  • Anesthetic Risk and Evaluation
  • Administration of Anesthesia
  • Pre-anesthesia evaluation
  • Post-anesthesia evaluation
  • Discharge
  • PI required
  • Healthcare-associated infections
  • State Exemption of CRNAs
  • Periodic Evaluation

Part 3 of 4 Infection Control, Safe Medication, Lab, Patient Services, Outpatient, and Discharge Planning


  • 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 proper insulin pens usage
  • 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 what CMS requires for discharge planning

Infection Prevention and Control and Antibiotic Stewardship Program

  • Final changes to infection control
    • Antibiotic stewardship requirements
  • Infection control worksheet
  • CDC and FDA health update
  • Investigating and controlling infections
  • Healthcare associated infections
  • Four challenges in infection control
  • Infection control orientation new employees
  • Surveillance, sanitary environment, and mitigation of risks
  • Role of leaders in infection control
  • Infection control officer

Safe Medication Practices

  • Preparation and administration
  • CMS IC worksheet and safe injections
  • Single and multi-dose vials
  • Fingerstick devices, scopes, glucometers, insulin pens


  • Services and staffing
  • COVID-19 reporting requirements

Patient Services

  • Diagnostic and therapeutic services
  • Supplies 

Outpatient Services

  • Outpatient department
  • Outpatient director
  • Final changes
  • Board and MS action 

Discharge Planning

  • Planning process
  • Patient involvement
  • Patient rights 

Part 4 of 4 Radiology, Organ Procurement, Rehab, Visitation, Medical Records, QAPI, and Swing Beds

Objectives – At the conclusion of part three, participants should be able to:

  • 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.
  • Recall that hospitals must have a visitation policy and patients must be informed 


  • Radiology services
  • Radiology staff
  • Scope of radiology services
  • Radiology policies required

Organ, Tissue and Eye Procurement

  • Definition of imminent death
  • Tissue and eye bank
  • Family notification
  • Organ donation

Rehab section

  • Order required
  • Plan of care requirements


  • Written copy of rights to patient and document
  • Patient advocate
  • When patient is incapacitated/incompetent
  • P&P required
  • Staff education required

Medical Records

  • Final changes
  • Timely access to medical records
  • HHA HIPPA changes – access
  • OCR fines
  • Medical record standards
  • Identification of author
  • Inpatient and outpatient requirements for medical records
  • Records System
  • Informed consent
  • History and physicals
  • Reports of examinations, diagnostic test results and consults
  • Discharge summaries
  • Preventing unnecessary readmissions
  • Documentation to monitor patient’s progress
  • Confidentiality of medical records
  • Retention of medical records 


  • Required process
  • Necessary members

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)

  • Eligibility
  • Payment
  • SNF Services
  • Resident Rights
  • Notice of Rights and Services
  • Privacy and Confidentiality
  • Mail
  • Access and Visitation Rights
  • Personal Property
  • Admission, Transfer and Discharge Rights
  • Resident Behavior and Facility Practices
  • Restraints, Abuse
  • Hiring of employees
  • Activities
  • Social Services
  • Dental requirements
  • Resident Assessment
  • Comprehensive Care Plans
  • Discharge Summary
  • Nutrition
  • Provision of Services

PART 5 CMS Hospital QAPI Worksheet for Critical Access Hospitals

CMS Final QAPI Worksheet

  • Number of deficiencies hospitals received
  • Final worksheet
  • 2020 changes
  • Indicators selected
  • Scope of data collection
  • Collection methodology
  • Number of projects
  • Focus – severity, high volume, etc.
  • RCA and causal analysis tracers
  • TJC Sentinel Events and framework for doing RCA
  • Interventions etc.
  • PI requirements and leadership
  • Board responsibility for PI

 CMS CoP Manual Standards on QAPI

  • Revised QAPI requirements November 29, 2019
  • CAH final QAPI under the Hospital Improvement Rule
  • CAH ten new tag numbers for QAPI in 2021
  • CMS memo on reporting into the QAPI system
  • Number of deficiencies in the QAPI standards
  • Ongoing PI program
  • No hospital wide QAPI program for CAH
  • Prevention and reduction of medical errors
  • Program scope
  • Measureable improvements
  • Analyze and tracking of performance indicators
  • Program data
  • Tracking adverse events
  • Ensuring compliance with program data requirements
  • Identifying opportunities for improvement
  • Board responsibilities for PI
  • QIO projects and changes in QIO functions
  • PI priorities
  • Issues to improve patient safety, reduce medical errors and ADEs
  • Three RCAs or root cause analysis
  • Number of PI projects
  • Documentation requirements
  • Executive responsibilities
  • Providing adequate resources
  • Resources: TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.


  1. Recall that CMS has a worksheet on QAPI
  2. Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  3. Discuss the rewritten the QAPI requirements CMS implemented for CAHs
  4. Discuss the Governing Board’s ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
  5. Recall that hospitals are receiving a high number of deficiencies in QAPI

CEO, COO, CFO, CNO, accreditation and regulation director, nurse managers, pharmacist, quality manager, risk manager, healthcare attorney, health information management personnel, social workers, dieticians, nurses, nurse educators, nursing supervisors, patient safety officer, infection preventionist, radiology director and staff, laboratory director, emergency department director, outpatient director, medication team, ethicist, director of Rehab (OT, PT, speech pathology, and audiology), OR supervisor, OR staff, CRNA,  anesthesia providers, activities director of swing bed patients, infection control committee members, compliance officer, performance improvement director and staff, and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met.

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

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.  Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University 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.

January 12; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the order prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.


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January 19
8:00 am - 10:00 am MST
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