Critical Access Hospital Conditions of Participation 2021: Part 5 of 5 (Webinar W1005)

Online Education   
Tuesday, February 16, 2021 10:00 AM - 12:00 PM   iCalendar

b>The fee for each session is $225 for GHA members, $195 for members of any affiliated GHA Society, and $295 for non-members. Contact the Education Department to register for the full series and the fifth session is free!

Please note: To support social distancing and remote work, a single registration provides unlimited lines for all employees and trustees of your hospital, including a link to view the recording. Please register just one person from your facility and have that person share the access information with others who wish to participate.


Laura A. Dixon, BS, JD, RN
Healthcare Risk Education and Consulting, LLC

Course Curriculum

The last session in our five-part webinar series covering the entire Critical Access Hospital (CAH) Conditions of Participation (CoP) manual from the Centers for Medicare & Medicaid Services (CMS) focuses on the revisedQuality Assessment and Performance Improvement (QAPI) standard and the final changes that were effective November 29, 2019. CMS implemented a similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule and Interpretive Guidelines are still pending. Nonetheless, Critical access hospitals (CAHs) had an additional 18 months to implement the new standards โ€“ or until March 2021.

The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI. The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys, and is an excellent tool to understand expectations from CMS.

Objectives: At the conclusion of part five, participants should be able to:

  • Recall that CMS has a worksheet on QAPI
  • Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Discuss the rewritten the QAPI requirements CMS implemented for CAHs
  • Discuss the Governing Boardโ€™s ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
  • Recall that hospitals are receiving a high number of deficiencies in QAPI


Performance improvement director and staff, risk management, quality staff, compliance officer, chief nursing officer, chief medical officer, patient safety officer, nurse educator, staff nurses, nurse managers, leadership staff, board members, accreditation staff, department directors, infection preventionist and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met.

Continuing Education Credits

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Each session is approved for 2 contact hours.

If you are registering for an out-of-state hospital association, please contact the education department at, or 770-249-4542.

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