Critical Access Hospital Conditions of Participation 2021: Part 4 of 5 (Webinar W1004)

Online Education   
Tuesday, February 09, 2021 10:00 AM - 12:00 PM   iCalendar

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

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). It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual, especially ones that apply to their department. You will learn how to do a gap analysis to increase compliance, and we will discuss common areas of deficiency.

There were over 300 pages of regulations for Critical Access Hospitals (CAHs) in 2020. In addition to several important memos regarding COVID-19, there were changes to discharge planning, antibiotic stewardship program, access to medical records, infection control, QAPI, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, changes to the swing bed requirements, life safety code and facility services, and revised emergency preparedness requirements.

Part Four: Radiology, Organ Procurement, Rehab, Visitation, Medical Records, QAPI overview, and Swing Beds

Objectives: At the conclusion of part four, 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


CEOs, COOs, CFOs, nurse executives and leaders, accreditation and regulation staff, pharmacists, quality managers, risk managers, healthcare attorneys, health information management personnel, social workers, dieticians, patient safety officers, infection preventionists, laboratory directors, emergency department directors, outpatient directors, medication team, ethicist, director of Rehab (OT, PT, speech pathology, and audiology), OR staff, CRNA, anesthesia providers, dieticians, radiology staff, activities director of swing bed patients, and compliance officers

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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