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Critical Access Hospital Conditions of Participation, Five-Part Series (W3001-W3005)

Tuesday, February 7, 2023
10:00 am12:00 pm

Dates: Tuesdays, Jan. 17, 24, 31, Feb. 7, & 14
Time: 10:00 a.m. – 12:00 p.m. CT

Lena Browning, MHA, BSN, RNC-NIC, CSHA & Susan Seeley, RN, MSN, NEA_BC with Nash Healthcare Consulting
Cost: $595 to NHA members (per hospital, no charge for additional lines, recordings available up to 60 days after the webinar)
Target Audience
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.

Course Curriculum
This five-part webinar series will cover the entire Critical Access Hospital (CAH) Conditions of Participation (CoP) manual from the Centers for Medicare & Medicaid Services (CMS). This program offers an excellent opportunity to educate every department in your hospital on all the CMS manual sections. The Critical Access Manual has seen multiple changes over the last few years. This series will supplement efforts to comply with challenging areas, including nursing care plans, necessary policies and procedures, medication management, and emergency preparedness. The series will also cover pharmacy standards, medication-related sections, and tag sections in the regulations and interpretive guidelines. Finally, attendees will learn what to do when a surveyor arrives at their facilities.

Learning Objectives:
At the conclusion of this session, participants should be able to:
Part One:
• Describe that CMS requires the board to complete a written agreement if the hospital wants to enter into a telemedicine contract.
• 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 hospital CoPs.
Part Two:
• Explain the pharmacists’ responsibilities that include developing, supervising, and coordinating activities of the pharmacy.
• Describe the requirements for CAHs to ensure that outdated drugs are not available for patient use.
• Recall the requirements for security and storage of medications, medication carts and anesthesia carts.
• Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.
Part Three:
• 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 be used only 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 a plan of care be completed.
Part Four:
• Explain the informed consent elements required by CMS.
• Describe the requirements for history and physicals for CAH.
• Recite what must be contained in the operative report.
• Discuss how the CAH must comply with the requirements for notification of the organ procurement (OPO) agency when a patient expires.
• Recall the CMS patient rights that are afforded to patients in swing beds.
• Recall that hospitals must have a visitation policy and inform patients about said policy.
Part Five:
• Discuss CMS Deficiency Date on QAPI.
• Describe Adverse Event Reporting requirements and what QAPI requires.
• Define the QAPI Conditions of Participation.
• Recite systems for identifying medical errors.
• Review CMS worksheets, including discharge planning, infection control and QAPI.
• Indicate additional resources, including the National Quality Forum.

Speaker Bios:
Lena Browning is a nurse leader and accreditation specialist with more than 25 years of experience in clinical leadership in acute care settings. As a principal consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled three interim positions as director of accreditation and was responsible for restructuring accreditation departments and leading organizations in compliance. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy (IJ) situations with all organizations getting the IJ lifted, and no condition level findings noted on return surveys.
Prior to consulting, Lena had over two decades of experience in accreditation and regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in compliance and performance improvement strategies.
Lena earned a Master of Healthcare Administration from the University of Southern Indiana and a Bachelor of Science in Nursing from Murray State University. She holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post resuscitation stabilization. She is also a member of the Association for Professionals in Infection Control and Epidemiology (APIC).
Susan Seeley has over 40 years of experience in the health care industry, both as a nurse leader and as a clinical consultant with a focus on patient care services and regulatory compliance. She is experienced in conducting mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education. Susan has helped organizations achieve continuous survey readiness and assists organizations with writing and implementing successful Plans of Corrections for survey deficiencies. She has also assessed quality programs, clinical operations, the structure and function of medical staff committees, and the implementation of peer review quality plans.
Prior to becoming a consultant, Susan spent 19 years as the chief nursing officer for a rural Florida hospital while working part time for the parent company as a clinical consultant for their more than 200 hospitals. She earned her Master of Science in Nursing Administration and her Bachelor of Science in Nursing from Barry University in Miami Shores, Florida. She is a registered nurse and holds an Advanced Nurse Administrator certification through the American Nurses Association.

These speakers have no real or perceived conflicts of interest that relate to this presentation.