TELNET COURSE T2861 PART 1 (WEBINAR) TELNET COURSE T2864 PART 2 (WEBINAR) TELNET COURSE T2866 PART 3 (WEBINAR) DATE: SEPTEMBER 26, 2013

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1 CMS Conditions of Participation (CoPs) for Critical Access Hospitals (CAHS): Ensuring Compliance This is a 3-part series; each program can be taken independent of the others. TELNET COURSE T2861 PART 1 (WEBINAR) DATE: SEPTEMBER 12, 2013 TELNET COURSE T2864 PART 2 (WEBINAR) DATE: SEPTEMBER 19, 2013 TELNET COURSE T2866 PART 3 (WEBINAR) DATE: SEPTEMBER 26, 2013 CAHs must comply with CMS regulations and interpretive guidelines for the Conditions of Participation. Attendees will learn in detail the CoPs listed under program topics. Specific problematic areas and recent changes will be addressed. Actions to take when a surveyor arrives at the facility will also be discussed. Numerous changes to these regulations were made March 15, Target Audience: CEO, COO, CFO, CMO, CNO, Nursing Leadership, HIM Director, Pharmacist, Dietician, Social Worker, Infection Preventionist, Radiology Director, ED Director, Outpatient Director, Ethicist, Director of Rehab, OT, PT, Speech Pathology and Audiology, OR Supervisor, Anesthesia Provider, Director of Swing Beds, Accreditation and Regulation Director, Department Director, The Joint Commission Coordinator, Performance Improvement Director, Risk Manager, Safety Officer, Compliance Officer, and Legal Counsel Faculty: Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is President of Patient Safety and Healthcare Education and Consulting and previously the Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. Prior to Sue s current role, she was the Director of Hospital Patient Safety for The Doctors Company and OHIC Insurance Company. She has conducted many educational programs for nurses, physicians, and other healthcare providers. Sue has authored over 100 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. *The speaker has no real or perceived conflicts of interest that relate to this presentation.

2 PART 1 Program Topics: Introduction Changes: July 16, 2012 and March 15, 2013 CMS memos CAH problematic standards CAH resources Conditions of Participation CMS websites Copies of documents by surveyor How to locate changes Rehab or psych distinct unit standards CMS survey and certification website Visitation regulation Telemedicine standards Survey Protocol Introduction Tasks in the survey protocol Survey team Task 1 Off-site survey preparation Task 2 Entrance activities Task 3 Information gathering/investigation Task 4 Preliminary decision making and analysis of findings Task 5 Exit conference Task 6 Post-survey activities 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 in a rural area or treatment as rural 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 assurance 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 Physical plant and environment Disposal of trash Storage of drugs Construction Maintenance Emergency procedures Life safety from fire Emergency fuel and water Emergency preparedness plan LSC waivers Fire inspections 1. State that CMS requires the board to have a written agreement for telemedicine services. 2. Discuss that CMS has a list of emergency drugs and emergency equipment that every CAH must have. 3. Recall that the length of stay in the CAH should not exceed 96 hours on an annual average basis. 4. Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs. 5. Recognize that hospitals must have a visitation policy and patients must be informed.

3 Program Topics: Introduction Governing body or responsible individual Nurse on duty Staff and physician responsibilities Physician supervision PA, NP, CNS responsibilities Provision of services Guidelines for medical management Services provided through agreements or arrangements Nursing services Drugs and biologicals Pharmacy Inspections/staff interviews Dispensing of drugs Pharmacist responsibilities Staffing Policies and procedures Medication therapy monitoring Pharmacy USP 797 regulations Emergency medicine kits Drug storage Nursing med carts/anesthesia carts Outdated drugs Survey of pharmacy Reporting adverse drug reactions (ADR) and medication errors Near misses/good catches High alert medication Definition of medication error required Trigger/indicator drugs Monitoring medication errors Medication alerts Beers list (developed by Dr. Mark Beers) Do not use abbreviations Sound alike/look alike drugs Non-punitive policies PART 2 Infection Control Investigating and controlling infections Healthcare associated infections Policies Orientation for new employees Role of leaders Infection control officer Dietary and Nutrition Policies Dietary compliance Qualified dietician Support staff Direct services Outpatient Services Outpatient director Rehab removed in 2013 Laboratory Radiology Staff Scope of services Policies required Regulations and Interpretive Guidelines Emergency procedures Contracted services Nursing care Observation of med passes/nursing care Changes in observation guidelines Nursing care plans RN for each patient RN supervising care Drugs and IVs Verbal orders Verbal order policy Culture of questioning Medication passes 1. Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy. 2. Discuss the staff and physician responsibilities for infection control, dietary, outpatient services, rehab, lab, and radiology. 3. List the required polices for infection control, dietary, outpatient services, rehab, lab, and radiology.

4 Program Topics: Medical Records Standards Identification of author Access to medical records Inpatient and outpatient requirements Records system Informed consent Procedures required for consent Medical necessity and the RACs History and physicals Discharge summaries Preventing unnecessary readmissions Response to treatment Confidentiality Retention Protection of record information Surgical Services Policies required PACU OR register Operative report Surveyor in the OR Surgical privileges Designation of qualified practitioners Anesthesia Services Anesthetic risk and evaluation Administration of anesthesia Pre- and post-anesthesia evaluation Discharge PI required Healthcare-associated infections State exemption of CRNAs Periodic evaluation PART 3 Organ, Tissue and Eye Procurement Definition of imminent death Tissue and eye bank Family notification Organ donation Special Requirements for CAH Providers of Long-Term Care Services (Swing beds) Eligibility Payment SNF services Resident rights Notice of rights and services Free choice Privacy and confidentiality Access and visitation rights Personal property Married couples Admission, transfer and discharge rights Transfer and discharge Payment of care Content of notice Resident behavior and facility practices Restraints Staff treatment of residents Hiring of employees Activities Social services Resident assessment Comprehensive care plans Discharge summary Nutrition Provision of services 1. Explain the informed consent elements required by CMS. 2. Describe the requirements for history and physicals for CAHs. 3. List what must be contained in the operative report. 4. Discuss what CAHs must do to comply with the requirements for notification of the organ procurement (OPO) agency when a patient expires. 5. Name some of the patient rights that are afforded to patients in swing beds.

5 Registration: There is a site fee of $ for NDHA Member Hospitals and $ for Non-members per session for this course. NDHA member fee to attend all 3 sessions: $ (a savings of $75.00). Member Hospital refers to an individual freestanding facility, not a hospital system. The registration fee provides you with one phone number, Web connection and a downloadable handout. Numerous people at one physical site are encouraged to participate in the Web Conference through one registration (utilizing the same telephone/web connection). If any additional locations or facilities are added into your connection, additional registration fees will be charged. If participants at your site require more than one telephone/web connection, additional registration fees will be charged. Prior to the program you will receive an containing instructions on how to connect to the conference. This will also contain codes to access the conference call. Advance registration by August 29, 2013 is required to ensure delivery of instructional materials. A late fee of $25.00 will be charged for any registrations after this date. This fee is necessary, as we are being charged a late fee for any last minute registrations that require an overflow line on the bridge. If you do not receive an from Linda Simmons prior to the program with your handouts and dial-in information, please contact her at Please contact Linda Simmons at or lsimmons@ndha.org for further information. You may register by fax (701) , online at under Education or by mail PO Box 7340, Bismarck ND Registration fees are non-refundable unless notice of an individual s cancellation is received at NDHA five working days prior to the event, in which case a cancellation fee of $50.00 will be deducted from your registration fee. If notice of cancellation is received after this date, there is no refund. You will be billed whether or not you attend the program. Part I: September 12, 2013 CAH CoPs Part 1 Part II: September 19, 2013 CAH CoPs Part 2 Part III: September 26, 2013 CAH CoPs Part 3 NDHA Members attend all three sessions for $ (a savings of $75.00) Facility Contact Name/Title Phone Number