Critical Access Hospital (CAH) Conditions of Participation 2021: Ensuring Compliance - Part 1
Description:-
Part 1 of 4 - Introduction, General Information, Memos, Relevant Laws, Safe Injections, Advance Directives, Emergency Services, and Observation Status
Objectives:-
At the conclusion of part one, participants should be able to:
- Describe that CMS requires that the board must enter into a written agreement for telemedicine services
- Discuss that CMS has a list of emergency drugs and emergency equipment that every CAH must-have.
- Recall that the length of stay in the CAH should not exceed 96 hours on an annual average basis.
- Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.
Agenda:-
Introduction
- History
- Discharge planning and the Hospital Improvement Rule
- Most recent changes
- New tag numbers in 2020
- CMS memos
- ISMP IV Push Guidelines
- CAH problematic standards
- CAH Resources
- Conditions of participation
- CMS 3 Worksheets
- How to find manual, survey memos, and changes
- CMS websites
- Copies of documents by the surveyor
- How to locate changes
- Rehab or Psych distinct unit standards
- CMS Survey and Certification website
- Visitation
- Telemedicine standards
Survey Protocol
- Introduction
- Tasks in the Survey Protocol
- Survey Team
Regulations and Interpretive Guidelines for CAHs
- Swing bed module
- Compliance with Federal, State and Local Laws and Regulations
- Licensure of CAH
- Licensure, Certification or Registration of Personnel
- Status and Location
- Location Relative to Other Facilities or Necessary Provider Certification
- Compliance with CAH Requirements at the Time of Application Agreements
- Agreements with Network Hospitals
- Agreements for Credentialing and Quality
- Advanced directives
- Emergency Services, respiratory policies
- ED staffing
- EMTALA
- Equipment, Supplies, and Medication
- Blood and Blood Products
- Staffing/Personnel
- Coordination with Emergency Response Systems
- Number of Beds and Length of Stay
- Observation, the two-midnight rule
- Number of Beds
- Length of Stay
Presenter BIO
Laura A. Dixon
(BS, JD, RN, CPHRM)
Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense, and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura 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.
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