Critical Access Hospital Conditions of Participation Part 1 (W4001)
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Credit Offered
1 HLT Credit
This is a recording of a live webinar delivered on Jan. 16, 2024.


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

There were multiple changes and new regulations for CAHs in 2020, including a change to all tag numbers in the manual. Many of the new tag numbers do not include interpretive guidelines or survey procedures. Other changes included 25 new tag numbers in infection prevention and control and antibiotic stewardship and 10 new tag numbers in QAPI. The regulations for Swing Bed changes are limited to Appendix W, but the interpretive guidelines and survey procedures are in Appendix PP.  

This series will supplement efforts to comply with challenging areas, including nursing care plans, necessary policies and procedures, medication carts and drug storage, informed consent, and medication administration. Finally, attendees will learn what to do when a surveyor arrives at their facilities. 

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, 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, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company 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.

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

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

  • Describe that CMS requires that the Board enter into a written agreement for telemedicine services. 

  • Recall the worksheets that a CAH can utilize as a self-assessment tool to enhance compliance efforts. 

  • Recite that CMS has a list of emergency drugs and equipment that every CAH must have. 

  • Recall that all CAHs must comply with EMTALA requirements. 

  • Discuss that the average length of stay in a CAH should not exceed 96 hours on an annual basis. 

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 8 contact hours.   

By attending the webinar Critical Access Hospital Conditions of Participation, Four-Part Series offered by Georgia Hospital Association, participants may earn up to 8 ACHE Qualified 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 Qualified Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualified Education Credit. 

Please complete the course evaluation to earn your certificate of participation.
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