Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2022 Update- 4 Part Series

Laura A. Dixon
From: Jul 06, 2022 - To: Dec 31, 2022
Recorded Webinar


There are over 700 pages of new regulations for CAHs for 2022, including a change to all the tag numbers with a new CAH manual. Most of the new Tag numbers do not include Interpretive Guidelines or Survey Procedures. CAHs must comply with the Centers for Medicare & Medicaid Services Conditions of Participation Manual for Critical Access Hospitals – Appendix W.

This four-part webinar series will cover the entire CAH CoP manual.CAHs hospitals must comply with the Centers for Medicare & Medicaid Services’ CoP manual for Critical Access Hospitals. The CMS regulations and interpretive guidelines serve as the basis for determining compliance and this manual will be discussed in detail as well as the revised changes. 

Multiple changes in 2022 will address requirements for the antibiotic stewardship program, access to medical records, QAPI, infection control, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, changes to the swing bed requirements, and more.

Changes also will include 25 new tag numbers in infection prevention and control and antibiotic stewardship and 10 new tag numbers in QAPI. The changes added the revised emergency preparedness requirements.  As for Swing Bed changes – the regulations are limited to Appendix W, but the interpretive guidelines and survey procedures are in Appendix PP.  

This session will help CAHs comply with specific CoP problem areas, including nursing care plans, necessary policies and procedures, medication carts and drug storage, informed consent, verbal orders, medication administration, protocols, standing orders, and emergency preparedness. There are many pharmacy standards and medication-related sections that overlap, which will be covered in detail.

Detailed Program Outline and Objectives:-

Part - 1 (Available for All Day) 

Introduction, General Information, Memos, Recent Laws, Safe Injections, Advance Directives, Emergency Services & EMTALA, and Observation Status

Learning Objectives:-

After part one, participants should be able to:

  • Describe that CMS requires the Board to enter into a written agreement for telemedicine services
  • Recall CMS 3 worksheets which a CAH can utilize as a self-assessment tool to enhance compliance
  • Describe that CMS has a list of emergency drugs and equipment every CAN must have
  • Recall 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



  • History
  • Deficiencies and problematic standards for CAHs
  • Resources for CAHs
  • How to find manual, survey memos, and changes
  • CMS websites
  • Hospital Improvement Rule and Discharge Planning memo
  • Additional recent memos from CMS that affect CAHs
  • ISMP IV Push Guidelines
  • Conditions of participation
  • CMS 3 Worksheets

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
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Coordination with Emergency Response Systems
  • EMTALA obligations
  • Number of Beds and Length of Stay
  • Observation, the two-midnight rule
  • Number of Beds
  • Length of Stay

Part - 2 (Available for All Day) 

Physical Plant & Environment, Emergency Preparedness, Governing Board, Pharmacy and Dietary

Learning Objectives:-

 After part two, participants should be able to:

  • Explain the responsibilities of the pharmacists that including 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 diet to meet the nutritional needs of patients and the requirements of a dietitian  



  • How to find the manual
  • Policy and Memo website
  • Access to Deficiency data

Physical Plant and Environment

  • Construction and maintenance
  • Equipment, preventive maintenance, and AEM
  • Physical environment
  • Disposal of trash
  • Storage of drugs
  • Life Safety from Fire
  • LSC waivers
  • Fire inspections

Emergency Preparedness

  • Moved to Appendix Z
  • Emergency Plan
  • Policies and procedures
  • Communication Plan
  • Training and testing
  • Power Systems

Organizational Structure and Governing Body/Individual

  • Governing body responsibilities
  • Appointment to medical staff
  • Telemedicine services and requirements
  • Disclosure

Staffing and Responsibilities

  • Staffing and responsibilities
  • Physician supervision
  • Transfer of patient
  • Patient admissions

Provision of Services

  • Patient care policies
  • Scope of services
  • Emergency medical services
  • Medical management

Pharmacy/ Drugs and Biologicals        

  • Pharmacy policies and procedures
  • Responsibility for pharmacy services
  • Staffing in pharmacy
  • Storage and environmental conditions
  • Security of biologicals
  • Handling of biologicals
  • Compounding and pharmacy responsibilities
  • Dispensing drugs/biologicals
  • Do Not Use abbreviations
  • Labeling and scheduled medications
  • Reporting ADR and medication errors
  • Inspections/staff interviews
  • Survey of pharmacy
  • Near misses/good catches
  • High alert medication
  • Definition of medication error required
  • Non-punitive policies

Dietary and Nutrition Services

  • Final change
  • Dietary policies
  • C&P to order diet
  • Meeting patient needs, diet order, following recognized dietary practices
  • Dietary compliance
  • Qualified dietician
  • Dietary support staff
  • Assessment of patients and order

Part - 3 (Available for All Day) 

Infection Prevention, Safe Medication, Lab, Provision of Services: Outpatient, Laboratory, Nursing; and Discharge Planning

Learning Objectives:-

  • Recall that the infection preventionist must be appointed by the board
  • Recall that CMS has an infection control worksheet that may be helpful to CAHs
  • Discuss that insulin pens can only be used on one patient
  • Describe that an order is needed to allow the patient to self-administer medications
  • Explain that there are three-time frames in which to administer medications
  • Discuss that CMS requires that a plan of care be done



  • How to find the manual
  • Policy and Memo website
  • Access to Deficiency data

Infection Prevention and Control

  • Targeted surveys
  • CDC vaccine storage and handling
  • Final changes to infection control and antibiotic stewardship requirements
  • Hospital Improvement Rule
  • CDC Core elements
  • Facility Wide program
  • Infection control organizations and following nationally recognized standards and guidelines
  • Infection Control worksheet
  • Infection preventionist role and responsibilities
  • Healthcare-associated infections
  • Infection control orientation for new employees
  • Surveillance, sanitary environment, and mitigation of risks
  • Role of leaders in infection control
  • Documentation
  • Antibiotic Stewardship program
  • ASP leadership duties and responsibilities
  • CDC training and resources
  • 10 CDC Safe Injection Practices

Provision of services

  • Diagnostic and therapeutic services
  • Supplies
  • Outpatient services
  • Outpatient director
  • Inpatient services
  • Census and Ensuring compliance

Lab Services

  • Meet CLIA standards
  • Scope of services


  • Nursing services and leadership
  • Leadership duties
  • Supervision and Evaluation of care
  • Observation of med passes/nursing care
  • Changes in observation guidelines
  • Nursing care plans
  • RN for each patient
  • Drugs and IVs
  • Written policies and procedures for the administration
  • Timing of medications
  • High alert drugs
  • Safe opioid use and patient assessment
  • Sedation scales
  • IV medications
  • Blood and blood products
  • Verbal orders
  • Verbal order policy
  • Nursing care plan

Discharge Planning

  • Need for the effective discharge planning process
  • Discharge evaluation and plan
  • Review of the discharge planning process
  • The requirement to assist in PAC selection
  • Discharge Planning Worksheet

Part - 4 (Available for All Day) 

Radiology, Rehab, Visitation, Medical Records, QAPI, Organ Procurement, Swing Beds 

Learning Objectives:-

After part four, participants should be able to:

  • Describe the requirements for history and physicals for CAH
  • List what must be contained in the operative report
  • Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency
  • Recall that CMS patient rights are in the Swing Beds section.



  • How to find the manual
  • Policy and Memo website
  • Access to Deficiency data


  • Radiology services
  • Radiology staff
  • Scope of radiology services
  • Radiology policies required


  • Order required
  • Plan of care requirements


  • Policies and procedures required
  • When reasonable visitation restrictions can occur
  • Written notice to patient and document
  • Role of a support person
  • When a patient is incapacitated
  • When there is more than one support person
  • Staff education required

Medical Records

  • Timely access to medical records
  • OCR actions for failure to comply
  • Patient rights – timely access, copy
  • Medical record requirements
  • Content of medical record
  • Informed consent requirement
  • Discharge summaries
  • History and physicals
  • Description of response to treatment
  • Entries into the medical record and identification of the author
  • Confidentiality of the medical record
  • Release of medical records
  • Retention of records
  • The new standard – reasonable effort for notification

Quality Assurance Performance Improvement - QAPI

  • New requirements for CAHs
  • Changes to the QAPI program
  • Requirements of a QAPI program
  • Definitions – Adverse event and error
  • QAPI standards
  • Interpretive guidelines and survey procedures pending
  • Data collection and analysis
  • Previous standards and guidelines

Organ, Tissue, and Eye Procurement

  • Requirement for policies and procured
  • Need agreement with OPO, and/or Eye and tissue bank
  • Need for staff training
  • Definition of imminent death
  • Tissue and eye bank
  • Family notification
  • Organ donation

Special Requirements for CAH Providers of Long-Term Care Services

(Swing beds)

  • Rewritten and four changes in 2020
  • Requirements/Eligibility for Swing beds
  • Payment
  • SNF Services
  • Resident Rights
  • Exercise of Rights
  • Notice of Rights and Services
  • Free Choice
  • Privacy and Confidentiality
  • Mail
  • Access and Visitation Rights
  • Personal Property
  • Married Couples
  • Admission, Transfer, and Discharge Rights
  • Transfer and Discharge
  • Resident Behavior and Facility Practices
  • Restraints, Abuse
  • Staff Treatment of Residents
  • Hiring of employees
  • Activities
  • Dental requirements
  • Resident Assessment
  • Comprehensive Care Plans
  • Discharge Summary
  • Nutrition
  • Specialized rehab services

Who Should Attend:-

  • CEOs
  • COOs
  • CFOs
  • Nurse executives
  • Accreditation and regulation director
  • Nurse managers/supervisors
  • Pharmacists
  • Quality managers
  • Risk managers
  • Health information management personnel
  • Social workers
  • Dieticians
  • Nurses
  • Nurse educators
  • Patient safety officer
  • Infection prevention
  • Radiology director
  • Laboratory director
  • Emergency department directors
  • Outpatient director
  • Medication team
  • Ethicist
  • Director of Rehab (OT, PT, speech pathology, and audiology)
  • OR supervisor
  • OR staff
  • CRNA/anesthesia providers
  • Dietician
  • Radiology staff
  • Infection control committee members
  • Pharmacists
  • Compliance officers

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