Description

Part 1 of 4 - Introduction, General Information, Memos, Relevant Laws, Safe Injections, Advance Directives, Emergency Services, and Observation Status

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 for telemedicine services 
• 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.
• Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.

Agenda:-

Introduction

• History
• Discharge planning and the Hospital Improvement Rule
• Most recent changes 
• New tag numbers in 2020
• CMS memos
• ISMP IV Push Guidelines
• CAH problematic standards
• CAH Resources
• Conditions of participation
• CMS 3 Worksheets
• How to find manual, survey memos, and changes
• CMS websites
• Copies of documents by the surveyor
• How to locate changes
• Rehab or Psych distinct unit standards
• CMS Survey and Certification website
• Visitation 
• Telemedicine standards

Survey Protocol

• Introduction
• Tasks in the Survey Protocol
• Survey Team

Regulations and Interpretive Guidelines for CAHs

• Swing bed module
• Compliance with Federal, State and Local Laws and Regulations
• Licensure of CAH
• Licensure, Certification or Registration of Personnel
• Status and Location
• 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 
• Advanced directives
• Emergency Services, respiratory policies
• ED staffing
• EMTALA
• Equipment, Supplies, and Medication
• Blood and Blood Products
• Staffing/Personnel
• Coordination with Emergency Response Systems
• Number of Beds and Length of Stay
• Observation, the two-midnight rule
• Number of Beds
• Length of Stay