Critical Access Hospital Conditions of Participation series
(IHA 8.1.23)

Dates: Tuesday, August 1, August 17, August 29
Time: 10:00 a.m. – 12:00 p.m. CT

Speaker:
Nancy Ruzicka
Cost: $395 to NHA members (per hospital, no charge for additional lines, recordings available up to 60 days after the webinar)

PROGRAM OVERVIEW
This three-part webinar series will provide an overview of the critical access hospital conditions of participation regulations, interpretative guidelines and related quality, safety and oversight letters to state survey agencies. There have been many new regulations and interpretative guidelines that have been promulgated for critical access hospitals over the last few years. This series will assist in efforts to comply with challenging new areas, patient rights, infection prevention and antibiotic stewardship emergency preparedness, QAPI and other commonly cited areas of non-compliance.

SESSION ONE –Tuesday, August 1
This session will focus on the critical access hospital conditions of participation for rural health networks, compliance with federal, state and local regulations, location, emergency services, beds, length of stay, physical environment and emergency preparedness.

LEARNING OBJECTIVES
• Describe Centers for Medicare and Medicaid Services’ expectations for physician, providers and telemedicine providers credentialing including external peer review.
• Describe required notifications to state survey agency and CMS.
• Discuss physical plant requirements.
• Discuss relocation and off-site premise requirements.
• Explain emergency preparedness requirements including planning.
• Explain the average length-of-stay requirements.
• Explain what types of emergency equipment and drugs that every critical access hospital must have.

SESSION TWO –Thursday, August 17
This session will focus on the critical access hospital conditions of participation for organizational structure, staffing, staff responsibilities, clinical records, surgical services and provision of services including nursing, pharmaceutical, laboratory, radiology and rehabilitation service standards.

LEARNING OBJECTIVES
• Describe history and physical examination requirements.
• Describe surgical and anesthesia documentation requirements.
• Describe the minimum informed consent elements.
• Discuss medication administration requirements including self-administration.
• Explain and describe pharmacists’ responsibilities from procurement to dispensing drugs and biologicals.
• Explain plan of care requirements.
• Explain physician and mid-level practitioner responsibilities and staffing requirements.
• List operative report elements.

SESSION THREE –Tuesday, August 21
This session will provide an overview of the conditions of participation for infection prevention, antibiotic stewardship, quality assessment and performance improvement (QAPI), discharge planning and swing-bed services.

LEARNING OBJECTIVES
• Define the requirements of a QAPI program.
• Describe what constitutes an antibiotic stewardship program.
• Discuss minimum requirements for discharge planning.
• Explain basic requirements of swing-bed program.
• Explain the CMS minimum standards for an infection prevention program.
• Explain the new requirements for patient rights in critical access hospitals for all patients.

Speaker Bio:
Nancy Ruzicka is a consultant on state and federal rules, regulations and interpretative guidelines. Ruzicka previously worked as director of integrity and compliance and privacy official at MercyOne Des Moines and director of regulatory compliance at UnityPoint Health-Des Moines. She also has more than 20 years of experience with the Iowa Department of Inspections and Appeals. Ruzicka holds master’s degrees in health law and business administration and a bachelor’s degree in pharmacy, all from Drake University. She is certified in health care compliance and maintains her Iowa pharmacy license.