Critical Access Hospital Conditions of Participation, Five-Part Series (W6001)

Part One: Tuesday, Jan. 13 (10 a.m.-noon ET) 

Part Two: Tuesday, Jan. 20 (10 a.m.-noon ET) 

Part Three: Tuesday, Jan. 27 (10 a.m.-noon ET) 

Part Four: Tuesday, Feb. 3 (10 a.m.-noon ET) 

Part Five: Tuesday, Feb. 10 (10 a.m.-noon ET) 

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

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

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

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

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

Critical Access Hospitals (CAH) must comply with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) located in Appendix W in the manual. This five-part webinar series will cover the majority of the CAH CoPs manual. The regulations and interpretive guidelines serve as the basis for determining compliance.

There were multiple changes and new regulations for CAHs in 2020, and new United States Department of Health & Human Services (HHS) regulations on patient rights and obstetrical care in 2025. However, most of the new tag numbers do not include interpretive guidelines or survey procedures. The most recent major changes were additions to the regulations from HHS for patient rights, additions for integrated systems and emergency services, specifically related to obstetrical care.

This series will help CAHs comply with specific CoPs challenges, such as nursing care plans, necessary policies and procedures, drug storage, informed consent, and medication administration.

At the conclusion of this series, participants should be able to:

Part One:

Describe that CMS requires the Board to enter into a written agreement for telemedicine services.
Explain that CMS has a list of emergency drugs and equipment every CAH must have.
Discuss that all CAH must comply with EMTALA requirements.
Recall that the average length of stay in a CAH should not exceed 96 hours on an annual basis.

Part Two:

Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy

Describe the benefits and requirements for CAH to utilize Compounding Pharmacies
Recall the requirements for security and storage of medications, medication carts, and anesthesia carts
Discuss the requirement for dietary to meet the nutritional needs of patients and requirements of a dietitian

Part Three:

Recall that the infection preventionist must be appointed by the board
Describe responsibilities of the board toward the infection prevention and ASP program
Explain the three-time frames in which to administer medications
Discuss that CMS requires that a plan of care be done

Part Four:

Describe the requirements for history and physicals for CAH
List what must be contained in the operative report
Discuss what must be included and be demonstrated in a QAPI program
Recall that CMS patient rights are in the Swing Beds section
Describe the new requirements for obstetrical services

Part Five:

Recall that CMS recently added Patient Rights to the Conditions of Participation for CAHs
Explain that CMS has restraint standards that hospitals must follow
Describe that a hospital must have a grievance policy and procedure in place
Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
Describe visitation requirements including policies and permitted limitations

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long-term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 10 contact hours.

By attending Critical Access Hospital Conditions of Participation, Four-Part Webinar Series by Georgia Hospital Association, participants may earn up to 10 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.

If you need assistance with registration, please contact the education department at education@gha.org or 770-249-4529.