Governing Board, Agreements and Contracted Services, QAPI, Discharge Planning

Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This eight-part webinar series will cover the CAH CoP manual.

There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control and antibiotic stewardship, QAPI and Swing Bed changes.

This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and drug storage, and informed consent to name a few.

Objectives

• Describe that CMS requires the Board enter into a written agreement for telemedicine services
• Describe requirements for contract management for a CAH
• Describe the essential elements of a QAPI program and Board responsibilities
• Recall the requirement for when a discharge evaluation must be completed

Organizational Structure and Governing Body/Individual

• Governing body/Individual’s responsibilities
• Appointment to medical staff
• Telemedicine services and requirements
• Required disclosures

Agreements and Contracted Services

• Agreement with providers or suppliers
• Lab and diagnostic services
• Food services

Quality Assurance Performance Improvement – QAPI

• Changes to the QAPI program
• Requirements of a QAPI program
• QAPI standards
• Data collection and analysis
• Reference: Standards and guidelines for Acute hospitals

Discharge Planning

• Need for effective discharge planning process
• Discharge evaluation and plan
• Review of discharge planning process
• Requirement to assist in PAC selection

Appendix and Resources