Now, I would like to introduce our speaker to get us started with Part 1 today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC 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. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of 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 for the Western United States. Ms. Dixon is a registered nurse and attorney. Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we are excited for you to kick us off with Part 1 today. Okay. Thank you, Lindsay, and welcome, everyone. As she mentioned, this is Part 1 of 4, and we're going to be covering the entire Critical Access Manual. When we're doing this program, if you happen to have or you're part of a system where there's an acute hospital, those are going to be coming up, but there may be some overlap in what you hear, and that's just normal for CMS to do that, but there's also some very special items for you as a Critical Access Hospital, and it's meant to help you out. And so that's why it's so helpful when you can listen to these programs to really stay up with what is going on. Now, I do want to also put in one caveat. CMS is required to update the manuals at least every five years. Your manual was last updated in 2020, so that means they're due this year. With the change in the administration, I have no idea when that is going to occur, and in fact, CMS probably doesn't know either when they will get around to making those updates, so just be aware. What we're talking about over these next four series is what's in place right now. I don't think they're going to change much. That's my gut. I have a feeling what they'll do and what I believe they'll do is add more to what they should have done with the last update. That's the interpretive guidelines and survey procedures. That's what I believe they are going to do, get around to getting those beefed up for or at least put out in publication. For all of my programs, I include my disclaimer, and that is our program today is strictly informational only. It is not meant to serve as legal advice nor establish that attorney-client relationship. Please consult with your own in-house counsel, legal representative, whoever that happens to be, for advice on your particular situation. I can only give you information on what does CMS say you need to do or what they are really not concerned about. Why are we here? Those of you who have gone through a survey know you may have gotten the statement of deficiencies where you have to do that plan of correction, especially on those higher level what they call condition levels. Of course, no one wants to get notice of the involuntary termination of the Medicare agreement. That's when they've been out for a survey, things haven't been done, perhaps they're not level to what they wanted or what expected, or you just didn't let them in. That can be another reason for involuntary termination. I'm going to do a brief overview of how this all works. First off, if you participate in Medicare or Medicaid, in other words, you get those payments, you have to meet everything within the manual, the conditions, everything. And that's for anybody in your facility. Doesn't matter if they're Medicare, Medicaid, Blue Cross, Blue Shield, Cigna, workers comp, it doesn't matter. You have to meet it for all of them. If you have deemed status, you know that means that you have met the requirements under those accrediting organizations. I'm going to say joint commission because it's the most familiar one. In that situation, you don't have to undergo a state survey. Joint commission will come in, they'll do their thing, and CMS says that's good. Not always, because sometimes CMS will come in with them or after them. And that's how this works. The regulation, again, starts in the federal register, but then CMS has their job. They have to put out any new regulation in what's called a transmittal. That goes to their surveyors to tell them, hey, this is new, this is what we're going to be doing. They have to develop those interpretive guidelines, also known as pretty much the rationale behind what they want to see, and survey procedures. And then again, update the manual. Three types of survey, certification when you're getting started, validation when they're coming back after a survey or if they're going to be following one of those accrediting organizations. And then finally, a complaint. That's where a member or someone else has notified the state that there's an issue going on and they're going to come in and follow up. Now, it doesn't always happen. They may send out just a verbal, but they may want to come see what's going on. So they may look at that in particular. In keeping up with your changes, those of you who work in compliance specifically, you might consider subscribing to the federal register. Then you'll get notice of when things are coming out. Confirm you have the most recent manual. Again, yours was last updated in 2020. If it is, look for the transmittal page. It will save you time. I will show you what these look like, by the way. And then the certification and survey website. Check it monthly. I check it daily because sometimes things creep in and I'm getting ready to do a program. Monthly is more than enough. And that will tell you when there's a new memo out. So we are talking about, and the overall appendix, by the way, in the state operations manual covers everything CMS has purview over. Some of these have combined. You will see psychiatric hospitals and hospitals individually have the same letter, A, because five years ago, they weaved those together because there was so much overlap. For your hospitals, criticals, you're in appendix W. Now, there's some other manuals I'm going to suggest you keep track of or have handy in your library. For example, appendix Q, when there's immediate jeopardy, when, again, there has been a complaint or an issue that's come up that CMS has learned about and it really impacts the health, safety or life of patients and others, then they're out within a couple of days. And they don't usually tell you when they show up. We know they're all now unannounced. It's just, what are they going to look at when they're there for an immediate jeopardy? For your appendix, this is what that index would look like. Those transmittals I mentioned, easy way to get to them. On the first page of the manual, you'll see that blue lettering. When you click that, that automatically takes you to the transmittal page. This is for every manual where there's been changes, by the way. And so you can see the last ones that were updated, major ones for you were back in 2020. Unfortunately, haven't had one. So I'm really hoping they put one new one out. And that's an example of when you open that link, what comes up, it tells you what's revised, what's new, what's been deleted. The survey memos, these are directed to their, they're surveyors, of course, but you get access to it. And it will tell you what's involved. When did it come out? What was it? Was it a revision? Was it new? Did something go all away like that second one here on slide number 14, where it says expired? The guidance for staff vaccination requirements, they retired that one. So that one is no longer in effect. And then this is just an example of what it looks like. It will tell you the date it came out, who it's in reference to, this is hospitals. And then they will give you a nice description. And if there's any additions to those particular manual pages, they attach them. They also have names and addresses and emails that you can reach out to the person responsible and ask a question directly. So deficiencies, I mentioned, no one wants to get notice of that deficiency report. But when it does happen, we know we have to act on it. The nice thing is you can access that data, and it's for everybody in the United States, any hospitals. It has the tag numbers. It will have a brief description of what happened or what was the issue at hand, not the plan of correction, but you can ask for that. And so to go to there, I have the link here on slide number 18. And by the way, on any of my links, you do have to copy paste. They won't automatically connect going through the PowerPoint. I've tried a couple of times, and it just wasn't being cooperative for me. So there is the link. Go to the bottom of the page, scroll down, where you see the hospital surveys. These are updated quarterly. And so once you flick that open, this pops up, just an example of one of those. It's a huge Excel document, but it's nice because with Excel, you can filter and sort and get right to where you want to be. And so as we go through some of these, I've added one or more problematic issues that cropped up in some of these areas that we're talking about. Some of them are very long, some appear repetitive, but nonetheless, you'll know which tag numbers and what was the issue at hand. It does have the name of the hospital, the date of the survey, et cetera. Problematic standards. I've got a couple of slides here to show you what have been problematic standards over the past couple of years. Discharge planning was a big one. In fact, they put out a memo on that. EMTALA always remains an issue. We're going to touch on EMTALA briefly today because normally, that is a two-part segment. So I'm going to hit the high points on EMTALA, what you really need to know and how that relates to emergency services. HMPs, verbal orders, medication and its administration, equipment, hand hygiene, suicide precautions, infection prevention and control. In short, pretty much everything came up to be a problematic issue with CMS. It wasn't just a one-off. It was those who had repeated issues. And most recently, there has been a lot going back and forth with health and human services on medical records and security, and particularly the electronic health information. How are we going to secure that? There was a new rule, proposed rule, just came out yesterday, and it talks about what they want to put into place for electronic health information and keeping it secured. How can you transmit it? How is that going to occur? These are just proposals. There's time to comment on that issue, on those proposed regulations. I can get that to Lindsay, if you wish. I'll make sure you have that link to that proposed rule where you can submit comments if that is what you want to do. I think it's going to impact pretty much healthcare providers across the board, whether it's hospitals or a physician's office. If you are interested, there is training that you can access. It's the same surveyor training that the surveyors go through. If you're new to your role, this may help you. What you can do is you click on where it says the catalog, I am provider, and then it will take you to that list of training. It's alphabetical. It gives you the timeframes that are involved. Even if you have a couple people working with you, if you have that luxury, or if you're just it, then this is really a nice way to get started. There is a very basic one, 24 hours long. You can get CEUs based upon it. It talks about some of the prerequisites to go through, but really a good way for an overall. I think I have some additional information in the appendix for you. If not, again, happy to get that to Lindsay. Memos, some of these came out, and these are just ones that came out within the last year or so. I do want to go over those because they will impact you one way or another. The first is texting. We do it. Everybody does it. It's helpful. It's so much quicker than trying to track down that provider, get them on the phone, and tell them what's going on, where you can just text it. Back in 18, they put out a memo, and they say, okay, we know this is crucial. It's essential. We have to do it. We have to look at it from a regulatory standpoint, but they noted at that time, texting of orders, that wasn't compliant with the conditions of participation, which means it has to be in the record. It has to be reviewed. It has to be maintained. Texting, it didn't happen. There was also privacy issues. What if that physician or that provider's family member or stranger got a hold of that phone, got access to it? There goes your privacy. Security, same thing. Integrity of your current system. Is that a complete medical record for that patient? If that stuff's not in there, and then retention, how long is that maintained within that system, within the cell phone? They noted that that wasn't compliant. In 2018, they recognized that most hospitals, including you, you didn't have the ability for those secure platforms, so you could incorporate that information into the medical record. Well, years have passed. Our technology has just skyrocketed, and as of February last year, they now put out a memo that you can text orders within the healthcare team if you go through that secure texting platform, and of course, that platform and what happens with that information is compliant with the conditions. I said, that's cool. We can get it, and so does that mean a different phone? I don't know. Maybe it does. I can't answer that. I'm not that tech-savvy when it comes time to cell phones and texting to know, does that work? But as long as you use that secure texting platform, your IT people are the ones who know that, then you can do it, otherwise, CPOE, your computerized ordering program, that's the way to go, especially for orders, but they also know, CMS knows, it's more than just orders that you are texting. The next memo happened to be Ligature Risk and Assessment. Now, you did see a picture of that memo, and it did say hospitals. Usually, they will say hospitals and critical access, and I want to bring this to your attention because you get patients. You get behavioral health patients. You get patients who have had an incomplete suicide attempt. We know that, so really, it would benefit you to listen, to hear this and to get information from this. There are three elements that you need to look at, so when you do get a patient who has not just always had an incomplete suicide attempt by ligature, but maybe just a suicide attempt, and now they're looking at other means. We have to look at patient assessment, staffing and monitoring, and really, what's your setup? Overall, they understand you do not, they don't expect you to have the same configuration, not only within your hospital, but throughout your entire hospital. They know that. Focus on whether the needs and risk of your patients, and that, of course, is based upon what is their presentation and their assessment, whether it's clinical or psychiatric, and then look at what actions you can put into place if you find those gaps. Maybe you did have an event, maybe you had that unfortunate event where that individual did attempt suicide with a ligature, whether it's while they're there or before admission. Use your common sense on that. Focus on appropriate measures rather than those overall blasting sort of events that you can, okay, it happened in the ER where we were supposed to watch them, and now we're going to put those same very rigid systems into place in maybe our step-down unit. Don't necessarily look at universal remedies, what fits within that particular unit. And the last one that came out most recently, very recently as a matter of fact, respiratory infection data. They put back into place and revised the reporting data for your respiratory infections, and they listed out the three main ones, COVID, influenza, and RSV. So beginning November of last year, November 24, you had to report weekly, electronically, information on those three areas. The idea behind this was that you as a hospital could be ready, you have good insight on what maybe some of your needs are. Maybe you have that older population where influenza is just taking them down, or you're getting a resurgence of COVID within your area. And so that's what that memo did happen to look like. I have the links on reporting what is required for you to do. There's even a fact sheet. So keep this handy if you have not already pulled this down and reviewed it. So here's what you need to do. All hospitals, with the exception of a psychiatric or rehab, or if you have a distinct unit within your critical access hospital, they then submit annually. Otherwise, you have to submit daily data on a weekly basis. And that goes to the National Clearinghouse there. It goes by Tuesday. So by tonight at midnight, you would have had to submit this data from the previous week. And that includes daily data for each day of the previous week. So it's the Sunday all the way up. They need to know this. Now, CMS recognized after some back and forth with some of the individuals involved, that was pretty onerous. And they couldn't get around to doing that, gathering the daily data and putting all that data into a system. So they recognized that maybe there's a second way you can do that. These are certain conditions that you have to meet. New admissions where you have confirmed illnesses of those three, COVID, influenza, RSV by age group, that you have weekly totals instead of daily data value. And I want to put this out. That's emphasis added that I put in there. So in other words, instead of gathering your daily data, you can do it by week and put that data out for those three conditions on new admissions. But you also have to include what's your staff bed capacity? How many can you take? What is your occupancy during that week? What is the prevalence of hospitalizations, ICU patients, according to each respiratory illness? And what you can do here now is that one day a week snapshot. Again, I added that emphasis. So it's less onerous of data that you are having to collect. One day a week, weekly, it helps provide new pathway for weekly reporting. Good balance between, again, they don't want it to be so burdensome that you're taking away from patient care. So that's what they're trying to do. You can also, maybe there's changes you want to implement based upon what your patient population needs are, what your technology advances are. Maybe you want to start with that second option. And then as your technology grows, or maybe you put a new system into place to help with that, you've identified a new way to do it, then you can go to the daily data reported weekly. So here's the, for 2025, the information collection, what you would include. One a day weekly snapshot. Weekly total new admissions. So again, these are the new options that you can put into place. So those were three of the major ones that I did want to talk about on the memos. So again, if you have distinct behavioral health or rehab units, you do yearly reporting, not weekly. Now, if you want to be ambitious and do weekly, they're not going to argue with you, but otherwise you're only required for that yearly reporting for those two. I'm going to go ahead now start with the conditions of participation. Before I go on, are there any questions, Lindsay, you want me to address before I move on to the meat of the program? It looks like just one question has come in and maybe you'll get to this, I'm not sure, but it asks if CMS has modified the critical access hospital, CIPs, to allow for a critical access hospital to participate in a unified QAPI program. Short answer, no, they have not modified that yet. Okay. That's coming up at a later series, but no, they have not modified it. And I just want to point out, I think you can go ahead and participate. It's just, you know, you won't get credit for it, so to speak, does that make sense? Where they still expect you to do your own QAPI and still participate, just don't get credit for it. That's the problem. I am hoping again with the new updates, they've changed their mind and said, yeah, you're missing out on a lot that you could help and gain access and gain information from. But at this point, no, sorry. Okay. There was a couple more that just came in as we open that up here that asked, does this include patients that are transferred out of the facility, admitted and or emergency patients? Yes. Any patient that you get in, I think you're talking to respiratory infections and yes, you do need to report that. And then the follow-up question here from someone else as for reporting purposes, just wanting to clarify for the respiratory admissions that swing bed residents are not included in that. Is that correct? That's excellent question. Right now, no, I would be very cautious on this one because CMS hasn't gone that far. It is a critical access hospital admission and they're in your hospital, they're under swing bed. That's a reimbursement issue. That is not a place issue. So I would take and go ahead and report those only because they're in your building, they're under your care and that swing bed is a reimbursement. It is not a care level. I mean, essentially for CMS, it is not a care level. You're still doing what they need to have done. I would still report swing beds at this point until I get clarification from CMS. I will send out a question to CMS for that. How soon I'll get it back? Good question, but that's a good one. I do believe you need to include swing beds. Perfect. Okay, I think that was the last question. Excellent. All right. All right, our conditions. Again, this is just an overview again. Appendix W, your tag number begins with a C and you start at 800. Last updated February 20. Not everything is in there. All we have right now are the regulations. That's it. When I get to these parts where CMS has not provided the current or updated interpretive guidelines, survey procedures, I'm gonna mention them from what was in the past or what's under acute because sometimes what they have in the regulation for acute is mirrored in yours. So there's no difference. That's why I believe they may just copy paste. And put what's in the acute and put it into yours, but they haven't done that yet. That includes, again, your manual has the regulation for swing beds, but the guidelines, the procedures are in appendix EP. That is the long-term care manual. I already mentioned if you have a behavior distinct unit, you know, it's separate. You're surveyed under A. It's not part of your 25 bed maximum. And the psych unit, those tag numbers are 1600 to 1726. There will be a separate program on that through Georgia Hospital Association that will talk about those special services because they're very different than what's in your hospital manual. And then again, that's where I just wanted to point out. Here is the appendix, the index or appendix A, and it talks about rehab and behavioral health unit. Usually on your survey team, for those of you who had not the experience, the person who shows up, if it's a person or a team, they have the option to make copies of things. If that's the case, have them make a copy for you too. Keep that so you understand what they're looking at. And maybe there's information you can add to that to support any issue that they're having. Now, you might want to abstract out what is not needed. And here I'm talking about your patient safety work product. If you participate in a patient safety organization, yes, they want proof you are, then that work product is something they cannot demand. You can give alternative information, but CMS said they know that's protected information. We kept it protected for a reason so that we can learn from those events that happened. So again, they cannot demand any material that you put into that patient safety organization as part of it. So just wanted to kind of bring that up if that ever happens. Here are these appendixes that you want to keep handy. Of course, your own, immediate jeopardy, but then there's a couple others. If you have swing beds, long-term care. EMTALA, Emergency Preparedness Life Safety Code. They're starting to cite more of us now on life safety code like fire alarms and egress and ingress. Floor conditions are starting to cite a little bit more on that. Emergency preparedness, we've all gone through one. Most of us have probably experienced it. Heaven knows, LA County, that's just a nightmare that they're going through and they've talked about how they've had to evacuate patients. And then finally, home health. If you have a home health unit, you might want to keep that one also handy. For the protocol, the surveyors do start ahead of time. They get their act together. They talk about, okay, who's going to do what? How much are we going to focus on? Who do we want to talk to? And then there's certain interest activities where they say, okay, pull me these charts. Get me this information. I want to talk to people here. I want to look at everything that happens within your hospital. Or they may just want to say, I only want to look at this area. Then they will put together all that information. They'll review your records. They'll remove your policy and procedures. That's what they want to look at. Then they come to a preliminary decision and an analysis of the findings. They may or may not do an exit conference. A lot of them usually do. They want to give you some notice that this condition was met, et cetera. And then of course, the post-survey activities where they go back, correlate everything and upload it to that national data, that those deficiencies, when they find them, that's when they're to put them in. The guidelines will give instructions to the surveyors. We know that. And the survey procedures. What do you have to look at? Now, those survey procedures, I want to point out, they're not all inclusive because sometimes those survey processes are so involved that they couldn't put them in the manual. It'd be massive. It's 800 pages, almost 600 pages now, let alone having to add them all. I believe in here, I have three resources in the appendix. These were the old survey tools that they had used back in 18 and 19 for acute hospitals when they were looking at QAPI, when they were looking at infection prevention and control and discharge planning. They found those three were major issues. And so they pulled together these survey tools and they have a lot more questions and things they would do. So I think I have the links. They're no longer used, never used in a critical, but they're really good tools if you want to do a gap analysis. And they will also go talk to your patients. One thing they're going to ask them right off the bat is, did they tell you about your rights as a patient? Were you notified of those or giving some information on it? Now, granted, some patients are so critically ill, they have no recollection of it. But what they're looking for is, are these posted in your hallway somewhere? Were they part of an admission packet if you're still doing the admission? These are your rights as a patient in our hospital. Swing bed, this is just briefly, I'm doing some initial information on swing beds. Because for some reason, CMS put this right at the beginning and then all of the regulations they put at the end of your manual. And that's for those who have that special long-term. And Lindsey did mention, we have a couple of questions. I think this is our first one, Lindsey. It is, and I'll get that one up here on your screen. Okay, and you should now see this question that says, our facility accepts swing bed patients from, and you can choose any of these options here, other facilities, other states, only within our facility or community. I'm possibly not sure, do not know here. Let me see, it looks like we do have one question, Laura, while we're waiting for some responses to come in for that, that says, are we reporting emergency department patients who are not admitted with COVID-RSV and flu to NHSN as a critical bed hospital? I believe you do have to, yeah. I think if you get a patient in, because what they wanna do is, how many patients do you have? So that's a very good question, but the way it's read, they did not distinguish yet ED patients from those patients. Did you get someone in that did have RSV? My thought on this is they intended, they intended for it to be strictly inpatient, because again, the goal is, do you know from what data you're collecting, you're prepared to take care of these patients, inpatient. So that is my reading, it's just unclear from that memo, that it's, maybe you do have to do, you might wanna do it for starters, but that's how I read it. They meant inpatients, not those you see in ER and send home, because you don't have to, you're done. Once you get them out of your hospital, that's it. So I know that's very confusing. The memo itself was a little confusing, but I will follow up with you, Lindsay, and confirm, yes, it's only inpatients. Perfect. Okay, we've gotten some good responses here. Yeah, I see a comment here that says, we only report admitted patients to our medical unit, not our ED patients seen in discharge from the ED. Yeah, and it wouldn't make sense to do your ED. It wouldn't, but no comment. Better safe than sorry, huh? Yes. Wow, a lot of you do from other facilities. That's wonderful, because they just, they can't. Some of these facilities can't take swing beds. Now, if you have a certain number of beds, you're prohibited from doing that. You have to transfer them out. So that's nice that you have that, they have that option that you have the service for them. So generally, they'll survey you under those requirements. The regulations only are in your manual. The guidelines, the procedures are in PP. No, there is no crosswalk. We asked, they said, no. You're reimbursed at that SNF level as opposed to acute care. And it, again, is reimbursement, not geographical. Now, I wanna point out one thing here, is that this can be for any patient. CMS does not limit it to simply Medicare patients. Again, it could be private pay, any patient, but you just have to make sure that to maintain your certification, you follow what's in those regulations, regardless of your payer. And of course, make sure that the policy, the carrier for that patient does allow for swing bed. That's the other thing you wanna check on. Generally, and these are for your Medicare patients. Yeah, you have to have a three-day inpatient qualifying stay. It can be one day at the other hospital, two at yours, and then they can go to swing bed. You can be, as long as that other facility is also qualified for CMS. It is not observation. Being an observation does not count. That's why that moon notice was put out there, so that they understand you're not inpatient, you're still an observation. And they also wanted that because some patients were getting those surprise bills when it's like, wait a minute, I wasn't in the ED, I was an observation. I had to go to swing bed, why aren't you covering this? And that's the reason why, an observation is not inpatient. Four-year bed count overall, you can have no more than 25 beds. Those are inpatient birthing beds, if they remain in there after they've given birth. But there's a lot they don't count. PACU, surgery, L&D, ED stretchers, exam tables, Medicare, those distinct units, again, those don't count. Observation beds. So there's a lot that doesn't go in, factor into that maximum 25 beds for account for you. So let's go ahead and now delve into the manual. So again, I just wanna briefly touch upon swing beds before we got into the heavy part of it, and that's a couple sessions down the road. So basically, again, you start with tag C, and the personnel qualifications are included right up front. Only the qualifications, as far as what they want practicing. It is not scope. That is the state that determines what this person can do. For qualifications, what is their education? What's their training? What will they accept? Because sometimes you will have a PA, it's been around forever, and maybe hasn't finished or gone through certain levels of that training that's now CMS wants, but they will take that experience as part of it. Now, of course, you as the hospital have to do the privileging credentialing, make sure these folks are still up to snuff and doing what you want them to do, and that they meet all the licensure requirements. I'm gonna talk briefly on a rural health network, because if you participate in it, which CMS says, yeah, you can, at least one hospital has to be a critical access. The other is your acute hospital. That there is a written agreement that talks about referral transfer between the acute and the criticals, that you have some way to communicate between each other whereas telemetry and critical care, maybe it's L&D telemetry, because that way you can share this data. That's why they call it a network. And then of course, the transportation to and from. Each hospital that you have an agreement for privileging and credentialing, and QAPI with one of the following. The hospital that's a member of the network, maybe you have a QIO equivalent, every state has one, and any other appropriate qualified entity that's within your rural health plan. On your designation, there has to be that RuralFlex program. Again, they can designate a critical access hospitals meeting the conditions of participation, that's nice. And for certification, you have to have been surveyed by your state and you're in compliance with all the conditions of participation. Any hospital has to comply with laws, no matter if federal, local, tribal, doesn't matter, you have to comply with them. At that time, the surveyor may wanna talk to your CEO. They wanna determine how is this done and who is responsible for that. The CEO, they are responsible for what happens in that hospital. They have to know and they have to be responsible for it. Not that they're doing it, but they have to know. And of course, the surveyor may send out any non-compliance to other agencies, such as OSHA, OCR, if there's discrimination. If you have an x-ray unit or something else that maybe there's hazardous waste, they may refer out that when there's been non-compliance. I wanna point out one thing, CMS does not have the authority to issue a monetary fine against a hospital. Your criticals, your acutes, they can send it off to the other people to do that. They just won't pay you, by the way. Or if you've been paid, there's an event, they may want their money back with interest, of course, that's pretty much a fine, but they cannot issue that monetary fine. OSHA can, OCR can, OIG, Office of Inspector General, they can. So you have a lot of people who you have to be responsible for and have oversight over you. That, again, CMS felt, okay, they could take care of it. Moving on to advanced directives. Like I said, you have to comply with all laws. And this happens to fall under the Patient Self-Determination Act. That is a federal law where competent patients have a right to make decisions as what's gonna happen to them when they become incompetent, when they become unconscious. And that's where the advanced directives come into place. In that case, then the staff has to comply with them. If they can't for religious beliefs or other beliefs, then we have to get that care put into another person. So again, they can make those advanced directives. We have to agree with them. We have to comply with them. We have to agree with them. We have to comply with them. And they can say, I don't want care. I'm gonna refuse treatment. That could be all or none. They can have someone step in their shoes, whether it's a support person, durable power of attorney to make those decisions. Now, normally your durable power of attorney comes into play when that patient is incompetent. And I'm meaning incompetent, meaning incapacitated also. They cannot make those decisions. So therefore this person has that legal standing to do so. That support person, they can designate who gets to visit them. Patient doesn't have to be incompetent to do that. Now, generally, of course you would take the patient's request over the support person if they are competent. And again, if they are incapacitated, durable power of attorney does that. You just have to give them the same information you would give to that patient so they can make these decisions. They can provide that consent. And you also, believe it or not, you also have to get the consent of a representative and a care decision, regardless of the patient's it's competent or incompetent. Sometimes that gets missed for certain hospitals where, yes, I have a representative, it's my daughter. They're my representative. Include the daughter in those discussions. And you have to take, by the way, if the patient's competent what they say over what the representative would say. If there's a conflict, generally there's not, but you never know, sometimes it could crop up. You should consider giving this information on advanced directives to outpatient observation, same day surgery. You're not required, but if you're getting a patient who for, because of their healthcare needs do come back, it's a familiar face, you may want to consider giving it to them, especially if it's like in same day and they're getting, or maybe a treatment, and that's the only way they get the treatment is because they're in same day. You might want to consider giving it to them. Document in the record, of course, when you do that, when they're incapacitated, you give it to their DPOA or family or surrogate. And I already mentioned they have that conscious objector clause. So if something does go against the beliefs of the care provider, then we recognize that and we get someone else to step in and take over the care of that person. We can't require a patient to have advanced directives. We just have to make sure our staff knows what are the policy and procedures surrounding advanced directives? What do we have to do? What do we have to know? Who do we go to when there's a conflict or an issue that comes up? Do you have an ethics committee? Maybe that's where you want to take them or maybe they start in risk management and go to the Ethics Committee, and include your Psychiatric Advance Directive or Mental Health Declaration. And again, even if there's no state law, you may want to consider that when you're starting to get those, or you have them in your community, it will save you some time if the event comes up. One other thing you have to do on Advance Directive is you have to provide community education on what it is. How do you do that? If you have a website, you might want to think about putting it there. Now, this is what CMS, this is what we have to do as a certified hospital in recognizing Advance Directives. And by the way, that means if you don't have some, or don't have one and want it, we're happy to help you get one. Most states will have that information on Advance Directives where it's a state approved form that talks about this is what will happen. My state, Colorado, just went through this a couple of years ago where they vastly changed it. And now we have to have two qualified healthcare providers who make the determination that an individual is there in that vegetative state, there's no chance they're gonna wake up, or nothing will help to improve their condition and they will die. And so they do have those. It's called a most form or a post form. So your state probably have them already. And if you pull those down, patient reviews it, signs it, it's the same as if they went to counsel and had an Advance Directive done. Now, one thing on Advance Directives, I do wanna point out, it's not a means to demand or obtain unnecessary or not accepted care. So if that patient, their Advance Directives say, I'm in a permanent vegetative state, I want to inject me as a medication that will stop my heart. You don't, that's not the means to do it. That is not what Advance Directives is supposed to do. It's not inappropriate care or unnecessary care. It's only, this is what I do and don't want done if I cannot make those decisions myself. There's also certain required disclosures that you as a critical access hospital have to do. You have to disclose if physicians own your hospital, and especially if they're practicing at your hospital. That also includes their immediate family and it has to be in writing. If also the owners don't refer to your hospital, they have to assign that attestation to that effect. They may own the hospital, but they go to somewhere else to admit patients. So they have to make that attestation to you in writing. They have to disclose to their patients where they do refer to them if it does need to be, that's a condition for getting privileges. And put it on your website. If it is a part of your advertising, our facility is hospital owned by these physicians and their immediate family. So that includes immediate family ownership, ownership by that immediate family. You also have to put out a notice if you do not have a physician on site 24 seven. And that again has to be in writing. All inpatients, outpatients, observation, usually people will put this up on a wall and say, we don't have a physician on site 24 seven. We have access to them and we can communicate, but they're not physically here. If that patient is admitted, I would have them sign that acknowledgement, initial it. I know there's not a physician presently on site, but you can get them. And again, you don't have to put them individual notices that sign up in the ED. That's more than enough. Post it and somewhere they're going to see it, but don't forget your other languages too. You may wanna put it in your most common. And for what I've been seeing in majority of the state that happens to be Spanish. How are you going to meet the needs of those patients in an emergency? And if you have a separate location and no physician again, you still have to give notice. So maybe they're at your offsite clinic. You may still wanna give notice. Hey, we don't have a physician on site, but we have access to them. In other words, you could be on the phone talking to them. Services that you provide according to what your state law scope of practice is. Any delegation that's permitted from a physician to maybe an advanced practice provider, of course, within their scope of practice. What can they do according to the state? We know you have to be licensed along with your personnel or certified, whatever your state does require. They do look at personnel folders. They wanna sample up and they may look at every level, whether it's your surgeon down to your secretary or your CNA. Usually it's those who are providing services directly to a patient. They wanna make sure that you've done what you need to do. Make sure they are licensed and that staff meet what they need to do. Certification, qualifications, training, education requirements. You can verify it through your board of nursing site. Who is licensed? Is it current? Is there a restriction on that license? Is it expired? We've had that happen. Do they have to have a DEA license if they're an advanced practice provider? So is that current? That's why all that needs to be in those personnel folders. In your critical carers, maybe you, you could do this. You can require them to have ACLS or PALS, NELS in the emergency room or ATLS, whatever it happens to be. It's not required by CMS unless the job description requires it. Then yes, then you do have to make sure it's there. And then, excuse me, you can also, they'll make sure the licensure information is up to date. On CEUs, if your state doesn't require it, you can. That's your decision. That's your choice. A lot of the hospitals, especially here in my state, they don't require it, but the hospitals do because they've figured we want these, we want our staff to be up-to-date, current, and knowledgeable about taking care of these patients. That's why they look at your policies also. Your status, where are you located? You have to meet location requirements with your initial survey, and then they reconfirm it with every other full survey. They talk about options for status as a critical access hospital and location. If you're in a metropolitan area, you don't qualify. And same with the urban area. If you're an urban hospital, that doesn't qualify. You can't be a critical access. It has to be located outside any area that's considered metropolitan statistical area. As far as how far, it's 35 miles from that next hospital. And it talks about an exemption if you're considered a necessary provider. I mean, we're talking the really frontier areas here where there's nothing around for 35, 40, maybe whatever mileage it happens to be. If you relocate, you physically move your building, and you're considered that necessary provider, then as long as you serve three quarters or provide three quarters of the same services area as before, and you're staffed by three quarters of the same people, same staff, then you can get that exemption. You have that pass on it. So this is when you as a hospital relocate and you're considered a necessary provider. If you cannot, three quarters of your population, three quarters of your staff, you have to cease business. So that's relocation. There is a grandfathering clause also available. So if you're there and you've been there forever, maybe you built a new place, you haven't moved, but another acute hospital or larger hospital comes closer to you, they move closer, you get that grandfathering pass on it. Because we've seen that happen where a larger hospital move closer to one of our criticals, critical didn't have to move, they didn't have to close because the other hospital moved closer. And so they will make sure that you're still in the same place if you were, if that hospital does move. Agreements, they included an overall, if you're a member of a rural network. Again, I mentioned you have to have that agreement with at least one hospital that's part of that network. And that talks about referrals, transfer information, pass back and forth, and emergency and non-emergency transfers. So for credentialing and inequality assurance agreements, again, if you're part of this network, then you can have an agreement on credentialing and QA. They have to be a member, QIO equivalent and other appropriate entity that the state has passed on, like a state rural health plan. Now I wanna qualify this in reference to the question, QAPI when you're in a system is different. That's where they haven't quite come around to saying, yes, you can participate. This is when you have an agreement with a network. I think it's a very fine line, but just make sure that you're qualified as a network in that rural health network. The agreements for quality assurance, they need to include how you're going to do record reviews as part of your quality component. What they're doing is that medical necessity for care at your critical access. And they will also, when they're there, the surveyors wanna see your policy and procedures on this rural network for credentialing. And then your agreement, how do you gain this information? How do you use it? How do you keep confidentiality with that information? Our state almost eight years now. And that was the big thing, that confidentiality. So that one hospital wouldn't have access, inappropriate access to your health information unless you had authorized or there was a reason for them to gain access. Telemedicine, yes, you get to use it. You probably have been using it for years. The board has certain responsibilities. They have to make sure there's a written agreement with either a hospital or an entity. And you also determine what categories you want to provide services to your hospital. Who's eligible? Because you have to appoint them to your board. You appoint them with the recommendations of the medical staff. And you also have to approve bylaws, other rules and regulations. And of course the board makes sure that the medical staff is responsible for the quality of care or accountable to you for the quality of care. So on telemedicine agreements, it can be two ways. Well, first off, the board has to make sure there's criteria for selection of those telemedicine providers. And that's the same that they would do for your own physicians. Character, competence, training, experience, judgment. That's the minimum that they expect. It can't be based because I'm board certified or I'm a member of this fellowship. I'm part of a hospital society. That's not enough. They want more meat behind it. And that, yes, indeed, you did review it. Because a surveyor, they want to see a copy, first off, of that agreement between the entity or hospital for telemedicine services. And by the way, on telemedicine, it used to be CMS didn't recognize those entities, those who maybe work at an office building outside, but they can tap in and have access and see what you're seeing on an x-ray, for example. And then they realized, well, that's happening and we're missing out on that as far as oversight. And so that's why with the entities, they agreed to have it, that you can use an entity. You don't have to go to simply a hospital. So back to the survey procedures. They want documentation that, yes, indeed, you reviewed and granted privileges to those providers at the other site. And what criteria did you use in granting those privileges? They want a list of those practitioners, their privileges, licensure information, if that's those who are providing from the other site, and that you reviewed their services, including if there's been a bad outcome, adverse event, or any complaints from the patient because of the services provided by that telemedicine provider. For contracts, yes, you have to have a contract on telemedicine. It has to be in writing if you are relying on the privileging and credentialing of the other site. So what am I saying here? If you are going to rely on the privileging and credentialing from, say, hospital B for their physicians to provide telemedicine services to you, you can't do that. You can't, but you need to have a written contract. And it must say that what their standards, privileging, credentialing by their medical staff meets the requirements of the conditions of participation. These hospitals have to be Medicare certified. They must be. The physician is privileged at that other hospital. They are licensed in the state where the patient's located. And that there's an agreement, there will be communication between the two of you on any adverse events back to that other entity because that other entity will then need to take action. They will need to do their peer review, whatever they need to do in those events. So that's what the contracts have to do. Okay, I'm going to move on to emergency services. I have a question coming up. So why don't we go ahead and do that? These are services within your hospital that you would get in. So Lindsey, you want to put that up and we'll see if there's any questions. Absolutely. And there are several questions. I'll go ahead and post this and then we'll get to those. This question should now be on your screen that says our response to emergencies within our hospital. Done by an established RRT, attended by the ED provider and floor staff, or possibly not well-organized. And I'm going to go over to the chat first, Laura, and make sure I get the first one here. So this says, just to clarify, the three-day qualifying stay is within the 30 days of discharge. Is that correct? 33 days inpatient stay. Okay, I'm sorry. Would you repeat that question just so I get it? Yeah, sure. It says the three-day qualifying stay is within 30 days of the discharge. Yes, yes. Is that correct? That is correct, yes. Perfect. And then for critical access hospitals, are we required to use a CMS-approved vendor for patient satisfaction? And is ED patient satisfaction required? No, totally your choice. Totally your choice. And when you look at those, you may identify a trend, but no, CMS does not require to use one of their certified vendors. Okay. Can a critical access hospital have an outpatient department that does not meet the location requirements? Most likely, yes, because if it's an outpatient department, it's part of your hospital, usually. I mean, unless it's like a physician's office, I guess they need a little more clarity. If it's urgent care, that's not a hospital. So that be included. They're looking at hospitals. Those who are licensed as hospitals for that mileage distance. So if that doesn't answer, you have more information, that would help. Perfect. Okay, and I see that came in from you, Rebecca. So if you just have any additional information, we'll be happy to follow up here. And it says, okay, is a hospital co-op considered a rural network? Ooh, that's a, I'm not familiar with that, but it is. You would have to look at your documentation and how it was drafted and put together. As far as, CMS has not delineated hospital co-op as far as a rural health network. So I'm sorry, I don't have an answer on that one. And then can you clarify, Laura, what the acronym is, I guess, for RRT? Oh, Rapid Response. Yes, Rapid Response Team. Rapid Response Team. I'm sorry, I forget. No, you're good. A question came in here there, but I didn't want to try to answer and be wrong. That's like a code team. A code team. Sometimes they call them the Rapid Response Teams. Perfect. And it looks like there's a couple more here. And this first one said, Medicare Advantage will cover swing bed when the patient is on observation and not inpatient. Should we do this? If that's what their policy allows. Because again, Medicare Advantage, it's through private insurance companies. So how, I have some concerns that they can establish different rules than what Medicare does. But Medicare recognizes there are private insurance companies that do that. So if that's what they say they're going to cover, then Medicare rules don't apply. It's Medicare patients. That's what they're talking about. Okay. And it looks like one more here that says, our original CMS letter when we changed statuses in 2001 about our critical access hospital states that we can see no more than 15 acute care patients. I see in the regs now that it talks about 25 beds can be swing bed patients. Is 15 acute care beds standard across all critical access hospitals or is there a way to change those acute care beds to more? So you're talking acute care or swing bed? I heard two different, I just want to make sure because usually what they're looking at, what's the ratio of your acute care beds to your swing bed? If you have swing bed, how are you going to admit a patient to acute care? And I mean, all your beds, all 25 beds are swing beds. Then you can't meet that requirement to take care of those patients. That's what CMS cap. If you have an infinite number of swing bed to your acute care bed capacity, they may have an issue with that. They may. I would be very cautious to say, oh, all 25 are swing beds. Now, granted it's reimbursement, but then you can't take an inpatient. And I think they would have an issue with that. And she just followed up saying, is the acute care capacity capped at 15? No, it is not. It's 25, 25 beds. How you use them, that's your decision. Perfect, she just said, thank you. Okay, wonderful. So that concludes all the questions that I see that were pending. I'm gonna go ahead and end this call and share those results. Okay, good. By the way, thank you for all the questions. Those are great questions. Okay, so ED and floor staff. Okay, some hospitals, they do have that luxury of a rapid response team. You know, it's respiratory, maybe lab to come up and draw ABGs real quick, staff, ED physicians. So that's great that you, those of you who can have that rapid response team. Not required by CMS, but it's there. Okay, emergency services. This is what you need to do. You as a hospital have to be able to provide emergency care for those outpatients and inpatients. The one thing it can't be is, oh, you have to go down the hall to, you have to go outside to our physician's office. You can't do that. It has to be at your hospital. And of course, meet the standards of care. Do your professional organizations establish that? CMS does not. Now I'm gonna just say this before we get into literature, restraints, et cetera, whenever that happens. Be very careful with that, because when you're looking at some of the requirements on restraints and seclusion, I think they're treading close to standard of care. But overall, it's your professional organizations that establish those standards of practice. Overall, you have to have a qualified medical director. Of course, your medical staff makes that criteria. Your policies and procedures that the medical staff put together says what care you're going to provide in the emergency department. They must be current and revised based upon what do your QAPI activities say needs work. Or we've looked at this, we wanna improve it. Not that anything's happened, we wanna improve it. You're integrating those services, your emergency services into your hospital-wide program. The medical staff puts out the qualifications for privileges for people to provide emergency care. Again, that's what I mentioned. Staff needs to be ACLS, PALS, NELS, whatever it happens to be, and adequately staffed with that trained personnel and adequate equipment. That seems all very common sense. On the categories, you determine who and how much you need. Are you going to use EMTs in your hospital to help with some of the basic needs? Okay, how many do you need? How many do you want? All RNs, great. You have to do ongoing assessments of your needs. Do we find we're seeing more pediatric patients? Are we seeing more behavioral health patients? Where maybe we need two rooms set aside for those we're concerned about. What training is required? Any other resources to address those demands? Maybe you're starting to see more RSV or more respiratory illnesses, and you've got to beef up some of your respiratory component. Care for inpatients and outpatient, that includes respiratory services that may be needed, intubation, ABGs. Any other tests that you have to have, such as ultrasound or CTs, the scope of what you're going to do for diagnostic and or respiratory therapeutic services, put that in writing, and the medical staff has to approve it. Now, you may have heard about some of the updated maternal fetal health requirements. Right now, that only applied to acute hospitals because they found you as a critical access hospital already have that in place. So you are ahead of the game in that respect. But if you are hearing about those updated requirements, just know that CMS has determined you have probably already done this, that you have prepared for it, and it's already there. Not that you can't do it, can't look at that, but it's already there. And I think we covered that in our last, we had a program last month on some of the updates. That was a very late year update. But here are the 14 policies, written policies that you have to have for emergency department. They are developed and approved by your medical staff with input from your advanced practice providers who work in the ED. Each type of service you're going to provide, what are the qualifications of those who are especially doing respiratory services and do you have to have supervision? In other words, are you going to allow your RNs to provide a nebulizer treatment? And if so, have they been trained? Do they need to be supervised? What equipment do you have? Who's going to assemble it? Who's going to run it? Safety practices, such as infection control. Needles, disposing of your respiratory equipment, maybe putting a person in isolation. Handling those therapeutic gases, oxygen. Cardio, CPR. How are you going to react to adverse reactions? Treatments, interventions, they come in and perhaps they got stung by bees and having a terrible reaction. Pulmonary function testing, therapeutic percussion. A lot of these you will see do relate to respiratory care, but you could be doing them nonetheless as an RN. Drainage, bronchopulmonary drainage, ventilation, aerosol, humidification, administration of medications. And then how are you going to obtain ABGs? These really focus, these 14 policies really focus on respiratory care. One other thing you might want to consider, it's not required, your triage protocols. Who's going to establish those? Who's reviewing them? And how are you going to make sure they are being followed? For the surveyor, they're going to make sure you have services that are under your qualified medical director. Again, this is your emergency services. Policy and procedures, they're there. They've been looked over. They've been updated on an ongoing basis. And you have enough personnel to provide the services. They will look at your policy and procedure on the services you provide. And of course, they want to go through a sample of medical records. They will interview your staff. They want to know, how much do you know for the participation in patient care or services provided here? Is it IV meds, not having cross-contamination, emergency respiratory services, management of injuries to extremities, central nervous system injuries? Are they in a collar when they come in? They also will look at your scheduling, your staff scheduling. Because what they want to make sure is you have enough people for the volume of patients you are seeing. If you do happen to do gases, if you're doing them or any other labs that are being performed through the emergency department, they are going to look for your CLIA certificate. They want to make sure that's current update. That could be through your regular central lab within your hospital. But the same thing, they want to make sure that they have that CLIA certificate. Your services have to be available 24 seven. If you don't have any inpatients, that's fine. You can close, but there has to be a way to meet that 24 hour emergency services. Maybe it's an RN who stays there. That's fine. You just want to make sure that whoever is on site, that practitioner or who's available, who's on call, has that experience and training. That they're available by phone, radio, and they can be physically at your hospital within that 30 minutes, 24 seven. So if you're in a rural area and maybe you're subject to some unpredictable weather, I understand Georgia did go through some very interesting weather last week between snow, ice and sleet. Can they be on site? You may want them to stay there overnight while they're on duty. Otherwise, equipment and supplies and medications, what would you have in an emergency case and that they're readily available. And they're not outdated, so we need to review those. Whatever types and qualities, don't forget blood and blood products. Now I'm gonna talk about blood and blood products later on as far as what you have to have. And by the way, you're not required to carry blood, but you must have some kind of blood product to stabilize a patient. And then anything that your state law or local law says you have to have on site. And following standards of practice, if you're in a farming community, do you have enough equipment, say, to handle those farming injuries for an immediate care? Or is it one where perhaps the person had an allergic reaction, whether it's bees or whatever it happens to be? The surveyor talks to the staff also. How do they make sure everything's available? And do they know where it's located? That's one of the big things. You may wanna keep them in one universal spot. So when in an emergency, you know where to run. Maybe it's in a locked cabinet, okay? Who has access to the keys? And can you get in there in time? As far as drugs, they do list out what they expect to have present. Everything from your antiarrhythmics, antihypertensive to antibiotics, electrolyte replacement, your IV solutions. What do you have available if you get somebody who's very dehydrated or is having seizures? Your anticonvulsants. So that list does have that. That's on slide 86 for those of you who are listening. And your equipment. These are the ones, again, they expect you to have, meaning they have to be on site. Everything from airways to IV therapy supplies, splints, NG tubes, tourniquets, oxygen. Please have enough oxygen that it's all there. On education, make sure staff, again, know where it's located and are they readily available? Is someone checking their expiration date? If it's a sterile pack, maybe you have a emergency delivery kit. When was the last time that was checked for expiration? How are supplies replaced? Who's responsible to do that? Is it the unit clerk? Is it the charge nurse? Is it the hospital? Is it the overall CNO or the hospital that they are responsible to go in and review that? When were these supplies last used? Has it been years? Maybe you wanna look at that supply again or a piece of equipment. And likewise with the equipment, they wanna make sure staff is knowledgeable on how to use it. Can they troubleshoot if something isn't working? And if not, do you have a backup for that piece of equipment? Who's going to maintain that piece of equipment? Is it going to be a contracted biomed? Usually that's who it is that would take care of it. Surveyors, they wanna look at your sterilized equipment for any expiration dates. Also maintenance schedules. When was the last time that piece of equipment happened to be monitored or checked over? And they also, believe it or not, they go into the exam rooms and they check the suction, the force of that suction. Is it adequate for them? And how they determine that, I can't say, they just will check that force of the suction equipment. So blood and blood products, I mentioned I talk about it. As far as obtaining it, keeping it, and then transfusing it, you have to have blood products for emergency 24 seven. You don't have to store blood on site, but you have to have something as far as a blood product. In doing this, you could have an arrangement of Red Cross, wherever that happens to be, or you can do it yourself. Whatever works for your hospital. If you're doing tests on blood, I mentioned you have to have a clear certificate because that's how you're surveyed under CLIA. If you're collecting it, collecting blood, this is for transfusion, you have to register with the FDA. If you're only storing it and you refer all testing to outside, you're not doing any test as defined by CLIA, then you don't have to have that certificate. But I don't know of any emergency department that doesn't do some form of testing, whether it's hemoglobin, hematocrit, occult blood, sugars, yes, you gotta have a certificate. You have to have a written agreement on blood between you and that testing lab, because what they wanna make sure in that agreement is how's it gonna get there, who's responsible, and what's the turnover time? How will you get reports on it? Otherwise, if you are storing blood, make sure you're doing it to prevent any deterioration. If you're type of cross-matching, then you have to have the right equipment. You do have an option. You can keep four units of O negative on hand. If you have blood that is not cross-matched, and this patient is bleeding out, you can release it if the physician signs off and it is an absolute emergency. So if you don't have the luxury of time to cross-match and that person has to receive that blood or they will die, that's an option you can do. You're not required, but you can do it. It is there. On storage, make sure it's under the supervision of someone who's qualified, whether that's another qualified physician, maybe it's an internal med or infectious disease, whoever that happens to be, or a pathologist. And if you blood bank by an arrangement, the medical staff needs to look that over, and administration, they need to review that arrangement and agreement to make sure. The surveyor wants to see the agreement. They really do. Personnel in your emergency department. You have to have, excuse me, yeah, you have to have a physician, nurse practitioner, clinical nurse specialist, whoever it is, someone who's trained in emergency care, on-call and immediately available within 30 minutes. That means on-site. If you are in a frontier area, and they describe that, less than six residents per square mile meets the criteria for remote by your state, and the state has determined that, okay, maybe it takes longer than 30 minutes, that's okay, if that's what's required for this person to get care. Again, that's a frontier area. So if you happen to have that, those are the requirements. An RN can meet that requirement for being on-site to evaluate. They have to have training experience. They can do a medical screening exam only if they're there. They're on-site, and they can step away from what they're doing and go down and see this patient. What they are, the patient's request for care is within that scope of practice and consistent with all of your state laws. And for a temporary period, you can do this. So I wouldn't have it full-time. That's the way I'm reading this. You have less than 10 beds, that's one other option. So you're really tiny, tiny hospital. You're in a frontier area, and the governor sends a letter to CMS that said, this hospital is so small, and it has less than 10 beds, and that the governor has consulted with the medical and nursing boards that there is an issue for these patients to get care, emergency services in particular. And these are the circumstances and how long we want this request to have. So that these RNs can't do that MSC. If that's granted, your nurses have to be on that list of personnel, and make sure you're reviewing it because they could come and go quickly. You have to submit that letter to the surveyor saying, hey, this is a letter we sent off. We have a shortage, and if we don't do this, we cannot provide care. Now, I wanna put a caveat in here. Your state law may be more stringent on staffing or any certain hours that you have to have. Just make sure checking your state law. So for example, your state law says, nope, you have to be open staff with an MD onsite 24 seven. That's what you have to do. So it may be more stringent. The surveyor looks at the call schedule for your providers. They will talk to staff. Who's on call? How do you reach them? Ever had trouble reaching them? They wanna see documentation that yes, indeed, the provider was there onsite within that timeframe. That's, of course, when they're offsite. Other things you have to do for emergency services, there has to be some coordination with your emergency medical service. So there has to be a way that you can get ahold of these physicians by phone 24 seven so they can get these calls. That you can give them information on what's going on with the patient, and they can give you information on treating them. Or maybe we need to refer them out. How do we do that? The surveyor looks at your policy and procedures. They wanna make sure that physician is always available. They want evidence that they're following them and that they're evaluated. In other words, they look at the nursing documentation. How long did it take for that provider to respond, that physician to respond to that call? And how do you contact them when you need them? How does the staff do it? Oh, we have a pager or we text them. We don't hear back in two minutes, we call them or five minutes, whatever it happens to be. Or we just simply call them, make sure they're available. Now, you've got it here. This emergency procedures, this is actually part of the provision of services chapter. And the provision of services chapter for criticals is very long and encompasses pretty much everything else that we haven't covered. From nursing care, medication administration, radiology, it's in that entire massive chapter. I wanted to include it because it's so related to emergency services. So you have to have a way that you provide services as a first response to life-threatening injuries or illnesses. Maybe they come in, they're admitted for observation or that they're admitted to the floor for rule out MI. And sure enough, they have the MI. You can do this by employees or contractors, but they have to recognize the need for this care at all times. And then there's appropriate interventions, treatment and stabilization. But that's why I wanted to include it because they kind of separated it out within the manual, but this really is an overlap of what you have to do. And so now moving on to EMTALA, our next to last section here. I wanna talk about this because in the acute manual, they took out EMTALA. For your current manual, it's still there. It's only the regulation. It is not the interpretive guidelines. That's in appendix V. That will have the survey procedure. What are they gonna look for? You as an overall hospital, you have to report to CMS. If you believe someone came in, was transferred to you from another hospital and they were not stable. I don't know how often that happens. I couldn't find data on it, but if it does happen, you must report it. You have to put signs that EMTALA does require that spells out what are the rights of a patient for examination and treatment. They just put out a new one. It's much easier to read. You can add your name to it, your local or the hospital. You can now put that on there. Before it was kind of this dull and boring list of rights, but now it's more user-friendly for somebody who is reading it and they're available in Spanish. So they are available. You have to keep records regarding EMTALA issues for five years after the date of transfer, if you're transferring them. You have to keep a list of all physicians who can provide more evaluation and treatment to meet what the patient needs. That could be stabilization and transfer. You must have policies, written policy and procedures when a physician or specialty can't respond beyond their control. They had a flat tire and can't get in there. If also you want to have or allow your physicians who are on call to do elective surgery at the time, that's your decision. You can allow that or say, nope. You have to keep a central log of anyone who comes to the emergency department. That doesn't matter if they refuse treatment, if they've left AMA, they left without being seen. If they refuse treatment, why? Ask them why, why don't you want this treatment? I mean, you came in here for a reason. What's going on that you don't want it? Could be monetary, but they need documentation. Were they transferred? Were they admitted? Were they stabilized and transferred? Or did you get to the point where you could discharge them home? That's what they want to see in that central log. You have to provide that medical screening exam to determine is something, is there an emergency going on with this patient? Now you do that within your capability and it has to be done by someone who's qualified. Unless indeed there is an emergency medical condition, you stabilize or do an appropriate transfer. Now, if the person shows up and it is very clear there is no emergency, you just screen them to confirm that. If you have determined at that point in time there is no emergency, EMTALA ends, that EMTALA obligation ends. Now, again, I did mention about the transfer as far as necessary abortions for the life and health of the individual, that is still permitted. There is certain viability. CMS has recognized 22 to 26 weeks, your state law may be different. So evaluate that, work with your council as far as any state requirements for when you have to do a necessary abortion, like the life and health of the mother. If you have an emergency medical condition and you can't take care of them, you stabilize within what you can do and transfer them. And this is everybody, not Medicare. If you admit them, normally EMTALA ends. But as I want to point out, there's one case law, one from the Sixth Circuit, that's around Ohio, Kentucky, et cetera. They have one case out there that says the obligation to care continues if they are admitted or admitted. If they're admitted, that's what EMTALA generally said. It's like, no, they're under more care, EMTALA's done. Okay, then you don't have anymore. If the patient refuses to consent to treatment, then EMTALA ends. If they're not gonna take care of them, you do what you can. If they say, no, I'm not gonna have that care, I won't consent to treatment, then what do you want us to do? You just can't delay the care or a transfer or the medical screening exam in particular to find out how are you gonna pay for this? Oh, we have to go get prior authorization from your plan. You can follow your reasonable registration process. So you can do that. So in other words, if they come in, you can ask, do you have to have your insurance card with you? That's okay to ask. You can ask if they have the card with them. You also cannot transfer unless it's appropriate. You can't take care of them. You don't have the abilities, you don't have the bodies. You just can't. And the other option is I wanna be moved. Yeah, I was in a car accident. Yes, I know I'm stable, I'm okay. I wanna go to that other hospital because my niece is close to there and she can take care of me. They can do that, just haven't put it in writing. And of course we do it appropriately. And then finally, there's whistleblower protections. You can't take action against an employee who refuses to authorize a transfer or if they report a violation. Can't take retaliatory action against them. And then finally, if there is a facility with specialized capability, they can't refuse to transfer unless they themselves are on bypass. That's very, very few and far between. I've only heard of one instance where the hospital, it was in a level one trauma. They were inundated. There was nothing. In fact, they had people backed up. I says, we can't take them. We need to find another hospital to get them sent over to. But that's a really limited scope where they say, we can't take that transfer. They usually cannot refuse it if they have that specialized capability. All right, our final area, I believe is number of beds and length of stay. And I'm gonna weave in observation here too. No more than 25 inpatient. Can be inpatient, swing beds, whatever you need. 10 distinct units, 10 bed distinct units. They're not included. You're under A. And by the way, you cannot intermingle those beds. So if you have, let's say you have a wing and it's all rehab, that's your distinct unit. You can't put a med surge patient in there. That's your distinct unit. That's what they want it to serve as and vice versa. You can't put a behavioral health. If they're supposed to be in the behavioral health unit, that's where they need to be. Observation, it's a well-defined set of clinically appropriate services. Usually I'm recovering from surgery. It's taking me longer to wake up. Or I just wanna watch them. They're not quite qualified for inpatient yet. They're not that sick, but I sure as heck don't wanna send them home. Inappropriate use, that could mean the beneficiary gets that increased liability. 20% of your customary charges and appropriately admitted as outpatient. No pre-schedule observation. We don't do that. It is not appropriate when it's a substitute for admission. Now, this doesn't mean, let's say you have to board a patient because you don't have a bed. Remember, that's different than observation. You're just observing them. Continuous monitoring, not okay. They usually probably have to stay in your ED, board them somewhere. They're stable. They just need diagnostic testing on a patient procedure. That's not observation. You're awaiting nursing home placement. Convenience to the family. Routine pre-op or recovery after routine. In other words, once in a while, you may have to have for an extended time or routine stop, routine between ED and inpatient. That is not appropriate use of your observation. What you do have to have is an order. Can't backdate it. Just saying because admit for observation, that's okay. That's what you need to have. You have to have documentation that this is not an inpatient bed. There are specific criteria for those services and it's different from your inpatient criteria. It begins and ends with the order. And again, no standing orders for observation. One thing, it's not in the appendix, in your appendix. It's part of the billing manual, but I want to point it out. It's a two midnight rule. If you have a patient that you fully expect to stay more than two midnights, the idea, the presumption is admit them because you don't want to game the system. Again, that's your two midnight rule. The length of stay generally Medicare won't pay if it's after 48 hours, unless something is more strict. Maybe you have a stricter state law. They can't say an observation longer than 24. So look at your policy. And again, your observation beds are not counted in your number and your average length of stay for 96 hours. Length of stay, by the way, they use that to assess the efficiency and effectiveness of the care you are providing. Also managing it, they know it's complex. You have to have coordination, including utilization management, discharge planning. So that's why length of stay, they're really looking at that length of stay. Have we really used our services to the best of the ability for the patient? Again, it's not inpatient. That's why you have to have evidence that that's not what you're using it for. They expect that reasonable relationship between size of inpatient and observation. So here's an example of a red flag that CMS, this is in the interpretive guidelines. Disproportionately large 10 bed observation unit, as opposed to how many other beds do you have? Because they may say that's outpatient, excuse me, overflow inpatient. So if you have, again, 10 bed observation unit and maybe have 15 inpatient, 10 swing beds, why do you have so many observation unit? What's going on with that? Again, I already mentioned what's not counted in your 25 beds. I won't go through all of this. Tables, that for observation, your dedicated units, stretchers. Hospice, you can have dedicated bed. They are included in your maximum count. But your length of stay, 96 hours, doesn't apply. That's hospice. Because Medicare doesn't reimburse you, they reimburse only the hospice portion of it. And then finally, length of stay, don't exceed your 96 hours, four days. That's average. All patients for the entire year. Your state fiscal intermediary, they determine whether or not you met that compliance. It's based on your census data. And if you exceed, then the intermediary will send a report to the regional office and a copy to the state agency. And so you may have to have a plan of correction. That's again, when your length of stay exceeds that average 96 hours. Why are they there so long? Is it something where, yeah, maybe they require that length of stay. They do require, but it's an average. So it brings me to my final one. We have a patient comes into the emergency department, shortness of breath, dyspnea, nausea, vomiting, history of severe anxiety. They treat him with diazepam, also known as Valium. Admitting labs, EKG, they're not real conclusive for an acute MI. So they send him to observation and further lab work. Just want to kind of keep an eye on him. That's totally appropriate. Hour after admission to observation, he starts getting these returns of system. Now he's starting to have an elevated T wave. And in fact, he's probably slipping his T wave. He's getting so bad. Definite signs of a positive. He's having an MI. And his troponin has gone up. He's returned to ER. Does Emptala apply? Yes or no? So Lindsay, I'll let you put up those questions and we'll see what they say. Perfect, okay. So you should now see those two options there on your screen. And while they are putting those responses in, Laura, would you like me to go through some of these final questions that we have? Absolutely, please. Perfect, so this one asks, are you seeing more APRNs as providers in critical access hospital emergency rooms? And it sounds like yes. If so, are there any regs? Outlining the requirements around using APRNs? If an APRN can cover the ER, can they also perform dual roles and cover as a hospitalist? That's a very good question. That depends on what your scope of practice is for your APN. Usually, your state may require supervision, oversight, or some kind of collaborative agreement between the nurse practitioner and the physician. They may. You, as a hospital, can require that too, even though the state said, eh, not necessary. But most states, they want some type of communication between the nurse practitioners and the physicians. Can they cover as hospitals? Again, it depends on what their scope of training is and their experience. Maybe they can be both. But the question is, if they're doing rounds as a hospitalist, who's covering the ED? Can they drop what they're doing, leave, and go to the ED? Okay. But again, how much are they having to do? That's like, I kind of equate that to the specialist who's doing surgery and they can't get there. Are you going to allow them to do non-necessary, oh, that optional work, in addition to being on call? I think being a hospitalist might take them away from the ED too much. But that's really what you would have to evaluate. And what does the state say they can for scope of practice? Can they be considered doing both dual roles? And with the amount of information and knowledge and experience they would have to have. Okay. And this next question says, the current supply of blood is so low and unavailable for critical access hospitals have a hard time getting blood. How lenient is CMS to this requirement? They haven't gone that far. I do see, there are several listservs out there that they talk about, hey, we're a critical shortage of some of these medicines that we need, including blood. We just simply can't get enough. And especially if you've had a massive trauma in your state or in your area where it's just impossible. That's why they want the blood products available that you do have to have available. If you simply can't get it and it's a national shortage, it's beyond your control. I would just have clear documentation on what efforts you have done to try and get that blood. Who did you talk to? How often? What was their response? What's available? How soon can you get it? Because yes, it has been an issue across the nation where there's just simply not enough blood. We know those really unique types, AB negative, where they have very, very vast shortage of supply. So I would just document your efforts, like try and have those blood products of other things that you can utilize. That's what you must have on site, as opposed to blood. Then maybe that's when you may have to transfer. Again, it could be also that other hospitals in the same boat you are. So I would just look at what you have done to make that happen. Okay, and then this other question says, can the central log be electronic? Yep, sure can. Yes, absolutely. Yeah, you don't have to use old school paper. Sometimes it's nicer to have that because then you can start collating. Hey, what are we seeing a lot of? Is it time of day? Is it day of the week? Not that you don't know that. Is it a particular illness that comes in? How many left without being seen? How many AMAs did we have? So absolutely, electronic's fine. CMS doesn't care the format. Okay, and then if you have acute care beds in your critical access hospital, are you paid under critical access for those beds or paid IPPS for the acute beds? I think you are paid critical access rates for acute beds. Again, some of the billing I don't get into because that's a whole can of worms. Yeah, I would check with them on that. Okay, and I think this is just a comment here, but it says we are unable to transfer emergent patients all the time. They get put on wait lists or we get told that there are no beds available. Yeah, yeah, and that's the, we're seeing that much, much more, especially for OB. Some of the hospitals are really running into the problem accommodating those patients for OB. Okay, I'm gonna share those results there for that final discussion question. Okay, again, observation is not inpatient, so they have not been admitted. My understanding is that if you're in observation and you go south, then EMTALA applies to the extent of what needs to be done. In other words, you examine them and start treatment until they're stabilized or admitted inpatient. So I would run them still through the same areas of observation, that they are admitted to observation, they are not admitted inpatient. This, I think we're gonna see it a little bit more when especially boarding comes into play, when it's that fine line between boarding and observation. Do I, don't I? And if they're in observation and they start to have signs of a stroke, get them, where do you take them? Do you take them back to ED? That's where you have to evaluate it. Especially if they go back into the emergency department, that's where you take care of them. It is a fine line right now, but my understanding of reading the EMTALA and observation, EMTALA would still apply. You would still have to go through those steps doing that screening exam, your docs right there or your care providers right there. They're going to do it. And then they're gonna start the process. They're stabilized, they're admitted, you're done. Unless of course you're in the sixth circuit. Now that sixth circuit case has not been, has not gone any further. They left it there. This was a patient, just as a little side note, this was a psychiatric patient who was admitted. He was inpatient for 10 days. Then they felt he was stable enough to go home. So he was home and I think it was 11, 12 days after discharge, he murders his wife. And the family, the family actually brought suit against the hospital for discharging not stable and that EMTALA was still around, they didn't get him stabilized. Even though he'd been inpatient for 11 days, 10, 11 days and said he's fine. They said, nope, EMTALA continues. Now that's again, just that one district. It hasn't gone outside of that district as of yet. I'm hoping that it won't go any further than that because that is a huge opener for issues for hospitals. If you knowingly admit the patient, get him stabilized, they go home and several days later, they commit this act. That to me is beyond your control. That was not something you could have foreseen at the time of discharge that he could have or would have done that at that time. He was not a danger to others at that time. Okay, Lindsay, I guess that's it for us. I do wanna just show a couple of those additional resources that I put out the memos that I talked about. Here's that ligature risk. So if you are seeing a lot of behavioral health patients, you might consider that for your ER. Just some general resources. I mentioned that there's also the Rural Health Information Hub, great site. It's free. They have an online library you can tap into as far as what's going on for that month. CMS did update their website for critical access. And if you're part of Rural Health, the state flex profiles, those are also there. And then really quick, the worksheets. I had mentioned these before. These are the ones CMS use for acute hospitals only. What they learned after they did this program, was they implemented and integrated into all of the massive changes back in 2019. Never used them in years, but it's a really good self-assessment tool if you wish to use those. So I still have about four more pages of resources, but those are there. If there's one that I mentioned and somebody would like to have the link, I can get it to you, Lindsay, if you wanna let me know. So with that, thank you, Lindsay. I will send it back to you, give folks like 15 more minutes of their day. So then go get it. Yeah, absolutely. Absolutely. We did have just a couple of questions come in, Laura, as you're going through those resources. And this first one asks, if EMTALA does imply to observation patients, then do you re-register them as an ER patient or do they remain in observation status? I would keep them in observation. That's a good question because that's going to be a billing issue. If you wanna get paid for your ER care, you might wanna think about re-registering them. You may not need to talk to the patient or anything, especially if you're in that shape and they do CPR. You could get a little trouble getting the information, but nonetheless, I would re-register them, say, yep, they had to come back in because they are admitted to observation. It's still kind of a gray area, in my opinion. Perfect. Okay, and then this says, what are the rules for boarding a patient? Is there a special boarding status that can be applied to patients that are just pending placement so that the length of stay is not affected? No, no, I don't know of any boarding status that would affect your length of stay. I really don't. Because yes, you're ready for admitting and they've been admitted, essentially, by intake. There's just no bed to put them. So I'm not aware of that. I just don't know that. Okay, I wasn't reading through. I think that was the final question there. Okay, perfect. I'm gonna post just some wrapping up information here there for you all in the chat. Just as a reminder that you are gonna receive an email tomorrow morning. If this is the first time that you've joined a webinar with us, just note that the email does come from educationnoreplyatzoom.us. And so that email very well may get caught up in one of your spam quarantine junk folder. So check those additional folders first if you don't see it in your inbox in the morning. And if it's not there, but you would just like to go back and access the recording, you can just use the same Zoom link that you use to join us for the live presentation today to also go back and access that recording. And just remember that the recording is available for 60 days from today's date. And you do see Laura's contact information here on the screen. But if you have any questions that maybe you just didn't get to ask today, you can always submit those to education at gha.org. We're happy to work with Laura to get those questions over to her. And she always goes above and beyond in her responses and we're so thankful for her doing so. And I did link the slides there for you all in the chat as well. So you should see that there where you can pull those up and access those slides. You will also receive a link to the slides in the email tomorrow morning as well. And if you're joining us as a member of the Georgia Hospital Association, please just note that at the conclusion of the full series, you'll receive the information regarding continuing education credits for this critical access hospital COP series. And if you're joining us as a member of a partner state hospital association, please reach out to your association for additional information regarding those CEs that they may be offering for you as well. Okay, thank you all so much for joining us today. Thank you for your wonderful questions. And thank you as always, Laura, for your time and information that you shared with us. We look forward to having you all back with us next week for part two. Have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay.

Laura Dixon

risk management

patient safety

Critical Access Manual

Critical Access Hospitals

CMS guidelines

compliance requirements

informed consent

patient rights

emergency services

EMTALA

telemedicine

hospital certification

swing beds