Source: https://fdaeducator.com/upcoming-webinar/Critical-Access-Hospital
Timestamp: 2020-04-07 04:32:41
Document Index: 228721177

Matched Legal Cases: ['art- 1', 'art- 2', 'art- 3', 'art- 4', 'art 2', 'art 3', 'art 4']

Critical Access Hospital (CAH) Conditions of Participation 2020: Ensuring Compliance- 4 Part Webinar Series
Product Id : HE257
Part- 1 : March 10th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes ( Pre Recorded )
Part- 2 : March 17th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Part- 3 : March 24th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Part- 4 : April 07th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
4 Part webinar series that covers the entire manual
Every hospital should be prepared in case a surveyor showed up at your door tomorrow. This four part webinar will cover the entire CAH CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that applies to their department. Hospitals have seen a significant increase in survey activity by CMS along with an increase number of deficiencies. Common deficiencies and how to avoid them will be discussed. Hospitals will learn how to do a gap analysis to increase compliance.
The October 2018 changes rewrote all of the swing bed regulations. They also now contain the swing bed interpretive guidelines and survey procedures which are under Appendix PP. Changes were made to the survey process and procedures.
This program will also discuss in detail the changes to the discharge planning standards. CMS will issue interpretive guidelines on these.
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. Attendees will learn details about the CoPs and what to do when a surveyor arrives at your facility.
CMS has issued many important hospital memos including privacy and confidential which is especially important in light of the HIPAA and the substantial penalties seen recently. Other memos include texting of orders, humidity in the OR and the effects of humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the QAPI program, prevention of Legionella, complaint manual update, OPO contracts, EBOLA, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.
Did you know that about a third of the CMS critical access manual was rewritten effective April 7, 2015 and three changes in 2016? This includes rewriting the section on nursing, drugs and biologicals, pharmacy, dietary, infection control, lab, radiology, contracted services, rehab section, IV medication, safe opioid use and blood, eligibility to be a CAH, and the availability for on call providers to respond to the emergency department.
While CMS is not using the infection control worksheet at CAHs at this time, the webinar will discuss why it is important to be aware of what is in this worksheet and to use this as a self assessment tool. There is also a final and revised worksheet on discharge planning and QAPI.
This seminar will help CAHs comply with specific CoP problem areas, including nursing care plans, legibility requirements, necessary policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness. There are many pharmacy standards and medication-related sections that will be covered in detail. Every tag section in the regulations and interpretive guidelines also will be covered. Attendees will learn details about the CoPs and what to do when a surveyor from arrives at your facility.
Detailed Program Outline and Objectives
PART ONE OF FOUR : March 10th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes (Pre- Recorded)
Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation
Objectives - At the conclusion of part one, participants should be able to:
Describe that CMS requires that the board must enter into 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.
Final changes: Discharge planning and the Hospital Improvement Rule
Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, texting, revised complaint manual, humidity in the OR, OPO contracts, equipment maintenance, EBOLA, CRE, ligature risks and scopes, glucose meters etc
CAH problematic standards
CMS 3 Worksheets
How to find manual, survey memos, and changes
Copies of documents by surveyor
How to locate changes
Rehab or Psych distinct unit standards
CMS Survey and Certification website
Tasks in the Survey Protocol
Swing bed module
Licensure of CAH
Licensure, Certification or Registration of Personnel
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
Emergency Services, respiratory policies
Coordination with Emergency Response Systems
Number of Beds and Length of Stay
Observation, two midnight rule
Part 2 of 4: March 17th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Pharmacy, Dietary, Maintenance, Board, ED, and Policies
Objectives - At the conclusion of part two, participants should be able to:
Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
Describe the requirements for CAH to monitor and inspect 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,
Emergency Procedures-moved to new appendix Z
Life Safety from Fire
LSC waivers
Services Provided through Agreements or Arrangements
Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, definition of medication error, adverse event, indicator or trigger drugs
Inspections/staff interviews
Staffing in pharmacy
Pharmacy USP 797 regulations
Nursing med carts/anesthesia carts
Survey of pharmacy
Reporting ADR and medication errors
Definition of medication error required
Trigger/indicator drugs
Standard of care for medications
Required pharmacy P&P
Non-punitive policies
C&P to order diet
Meeting patient needs, diet order, follow recognized dietary practices
Dietary support staff
Assessment of patients and order
Part 3 of 4: March 24th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Infection Control, Safe Medication, Lab, Patient Services, Outpatient, Nursing and Discharge Planning
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
Final changes to infection control
Antibiotic stewardship requirements
CDC and FDA health update
Investigating and controlling infections
Following national recognized standards and guidelines
Four challenges in infection control; MDRO, ambulatory care, communicable diseases and bioterrorism
Infection control websites
Infection control orientation new employees
Surveillance, sanitary environment, and mitigation of risks
Role of leaders in infection control
10 CDC Safe Injection Practices
CMS IC worksheet and safe injections
Single and multi-dose vials
Fingerstick devices, scopes, glucometers, insulin pens
Board and MS action
Observation of med passes/nursing care
Changes in observation guidelines
RN for each patient
RN supervising care
Drugs and IVs
Verbal order policy
Part 4 of 4: April 07th | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes
Radiology, Contracts, Emergency Services, Rehab, Visitation, Medical Records, Surgery, Anesthesia, QAPI, Organs and Swing Beds
Objectives - At the conclusion of part three, participants should be able to:
Explain the informed consent elements required by CMS,
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 when a patient expires,
Recall that CMS has many patient rights that are afforded to patients in swing beds.
Recall that hospitals must have a visitation policy and patients must be informed
Scope of radiology services
Radiology policies required
Written copy to patient and document
When patient is incapacitated
Staff education required
OCR now fining hospitals if access is not timely
Inpatient and outpatient requirements for medical records
List of procedures required for consent
Medical necessity and the RACs (recovery audit contractors)
Surgery policies required
Surveyor in the OR
Designation of Qualified Practitioners
PI required
State Exemption of CRNAs
Organ, Tissue and Eye Procurement
Definition of imminent death
Tissue and eye bank
Rewritten and four changes in 2020
Nurse executives,nurse managers,nurses, nurse educators, nursing supervisors
Healthcare attorneys, health information management personnel
Emergency department directors
Director of Rehab (OT, PT, speech pathology, and audiology)
OR supervisor, OR staff, CRNA,
Activities director of swing bed patients, infection control committee members, pharmacists, and compliance officers.
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