Critical Access Hospital Conditions of Participation: Ensuring Compliance: May 25

Time: 12:00 PM


Virtual – 12-2pm
This is the second of a four-part webinar series.


Per Each 2-Hour Webinar

IHA Members: $195 per member hospital or health system*
Non-IHA Members: $250 per organization*

*Please note the registration fee includes an unlimited number of connections within the same hospital or hospital system corporate office. Registrants will receive access to the program recording(s).

Register Online

In 2020 alone, the Centers for Medicare & Medicaid Services (CMS) moved ahead with over 700 pages of new regulations for Critical Access Hospitals (CAHs). Has your hospital maintained compliance with all of the Conditions of Participation?

This four-part webinar series will cover the entire Appendix W—the CMS CoP manual for Critical Access Hospitals. In addition, the webinars will explore CAH-specific regulations and interpretive guidelines, recent revisions and compliance challenges that CAHs have encountered across the country. Subjects covered by this series include:

Regulatory changes

  • Antibiotic stewardship program

  • Medical records

  • Quality assurance performance improvement (QAPI)

  • Infection control

  • Policy review time frames

  • Emergency preparedness

  • Dietician credentialing

  • Diagnosis quality and appropriateness

  • Swing bed requirements

Compliance challenges

  • Nursing care plans

  • Necessary policies and procedures

  • Medication carts and drug storage

  • Informed consent

  • Verbal orders

  • Medication administration

  • Standing orders

  • Emergency preparedness

This is a fast-paced webinar series. Please note the program summaries do not include each subject that will be discussed.


Part 2 of the series will review Conditions of Participation related to:

  • Physical plant and environment

  • Emergency preparedness

  • Organizational structure and governing body

  • Staffing and responsibilities

  • General provision of services

  • Pharmacy: drugs and biologicals

  • Dietary and nutrition


At the conclusion of Part 2, participants should be able to:

  • Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.

  • Describe the benefits and requirements for CAH to utilize Compounding Pharmacies.

  • Recall the requirements for security and storage of medications, medication carts and anesthesia carts.

  • Discuss the requirement for dietary to meet the nutritional needs of patients and the requirements of a dietitian.

Who Should Attend

CAH leaders and staff members responsible for the following:

  • Hospital administration (i.e. CEOs, COOs, CMOs, CNOs)

  • Compliance, accreditation and regulation

  • Quality improvement

  • Risk management

  • Facility management

  • Infection preventionists and infection prevention committee members

  • Healthcare attorneys

  • Health information management

  • Directors of radiology, laboratory, emergency department, outpatient care, rehabilitation (OT, PT, speech pathology, and audiology), operating room

  • Clinical leaders including physicians, nurses, pharmacists, social workers, dieticians


Laura Dixon BS, JD, RN, CPHRM
Director of Facility Patient Safety and Risk Management and Operations, COPIC Companies

Dixon has more than 20 years of clinical experience in acute care facilities. For the past six years she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC Companies. In this role, she provided patient safety and risk management training to individuals and facilities. Dixon is a registered nurse and attorney.