Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2025

Description

Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services Conditions of Participation located in Appendix W in the manual. This nine-part webinar series will cover the CAH CoP manual.  Included is a 2-hour program on Patient Rights – one of the most cited segments of the Manual. The CAH Manual does not include a specific section on Patient Rights as does the Acute manual, but hospitals must provide a safe environment for patients and method to ensure all patient rights are met.

There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control and antibiotic stewardship, QAPI and Swing Bed changes.

This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and drug storage, and informed consent to name a few.

CAH Conditions of Participation 2025 - Part 1

Part One of Nine: Introduction, General Information, Memos, Distinct Units, Advance Directives, Required Disclosures, Number of Beds, Length of Stay, and Observation Status

Learning Objectives:

• Describe how to find the manual and updates
• Describe what to expect with a survey
• Describe required disclosures for a CAH
• Recall what is included in the 25-bed maximum count
• Recall that the average length of stay in a CAH should not exceed 96 hours on an annual basis.

CAH Conditions of Participation 2025 - Part 2

Part Two of Nine: Patient Rights: Advance Directives, Giving Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, and Visitation, Restraint and Seclusion

Learning Objectives:

• Describe the requirement for a hospital to have a grievance policy and procedure in place
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
• Describe the various patient rights including providing consent, forming advance directives, and visitation rights
• Recall that CMS has restraint standards that hospitals must follow.

CAH Conditions of Participation 2025 - Part 3

Part Three of Nine: Emergency Services, Staffing and Responsibilities, Provision of Services, Emergency Procedures and EMTALA

Learning Objectives:

• Describe staffing requirements and supervision
• Recall the required14 emergency department written policies that must be present
• Describe that CMS has a list of emergency drugs and equipment every CAH must have
• Recall that a CAH must comply with EMTALA requirements.

CAH Conditions of Participation 2025 - Part 4

Part Four of Nine: Physical Plant & Environment, Emergency Preparedness

Learning Objectives:

• Describe expectations for a safe environment for patient care
• Recall the requirements for equipment maintenance and an alternative management program
• Explain the importance of maintaining ventilation, temperature, and lighting within a CAH
• Describe the mandatory training and exercises for an emergency preparedness plan,

CAH Conditions of Participation 2025 - Part 5

Part Five of Nine: Governing Board, Agreements and Contracted Services, QAPI, Discharge Planning

Learning Objectives:

• Describe that CMS requires the Board to enter into a written agreement for telemedicine services
• Describe requirements for contract management for a CAH
• Describe the essential elements of a QAPI program and Board responsibilities
• Recall the requirement for when a discharge evaluation must be completed.

CAH Conditions of Participation 2025 - Part 6

Part Six of Nine: Pharmacy, Infection Prevention, and Contro,l and Antibiotic Stewardship

Learning Objectives:

• Explain the responsibilities of the pharmacists including developing, supervising, and coordinating activities of the pharmacy.
• Recall the requirements for the security and storage of medications, medication carts, and anesthesia carts
• Describe the responsibilities of the infection preventionist
• Describe the responsibilities of the leader of the antibiotic stewardship program.

CAH Conditions of Participation 2025 - Part 7

Part Seven of Nine: Nursing, Clinical Records

Learning Objectives:

• Discuss nursing service and leadership requirements
• Recall the requirements for medication orders
• Discuss that CMS requires that a plan of care be done
• Recall requirements for contents of clinical records
• Discuss security requirements for clinical records and when “blocking” for access can occur.

CAH Conditions of Participation 2025 - Part 8

Part Eight of Nine: Radiology, Laboratory, Surgical Services, Anesthesia, Organ Procurement

Learning Objectives:

• Discuss compliance requirements for radiology and laboratory services
• List what must be contained in the operative report
• Discuss the required content for informed consent
• Discuss the requirements for pre-and post-anesthesia assessment
• Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency.

CAH Conditions of Participation 2025 - Part 9

Part Nine of Nine: Rehab, Dietary, Visitation, Swing Beds

Learning Objectives:

• Recall the requirement for an order for rehabilitation
• Discuss the requirement for dietary to meet the nutritional needs of patients and the requirements of a dietitian
• Recall the requirement for nondiscrimination in visitation policies and practices
• Recall that CMS patient rights are in the Swing Beds section
• Discuss the reporting requirements for allegations of abuse or neglect of swing bed patients.

Who Should Attend:-

• CEOs
• COOs
• CFOs
• Nurse Executives (CNO)
• Accreditation and Regulation Director
• Nurse Managers
• Pharmacists
• Compliance Officers
• Health information management
• Nurses
• Nurse Educators
• Nursing Supervisors
• Quality Managers
• Risk Managers
• Healthcare Attorneys
• Health Information Management Personnel
• Social Workers
• Patient safety officer
• Infection preventionist
• Radiology director
• Emergency Department Directors
• Outpatient Director
• Medication Team
• Ethicist
• Director of Rehab: OT, PT
• Speech pathology,
• Sudiology
• CRNA
• Anesthesia providers
• Radiology staff
• QAPI staff
• Policy and Procedure Committee
• Dietician
• Activities Director of swing bed patients
• Infection Control Committee Members