Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2024 (Part One of Eight)

Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This eight-part webinar series will cover the CAH CoP manual.

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.

Part One of Eight

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 25-bed maximum count
• Recall that the average length of stay in a CAH should not exceed 96 hours on annual basis

Introduction

• History
• Deficiencies and problematic standards for CAHs
• How to find manual, survey memos, and changes
• Recent memos that affect CAHs

Conditions of Participation

• Introduction
• Survey Protocol and Team
• Swing bed review module
• Compliance with Federal, State and Local Laws and Regulations
• Licensure of CAH
• Licensure, Certification or Registration of Personnel
• Advanced directives
• Status and Location
• Compliance with CAH Requirements
• Agreements with Rural Health Network Hospitals
• Number of Beds and Length of Stay
• Observation and the two-midnight rule

Appendix and Resources