CAH CoPs 2019: Ensuring Compliance — Part I of IV

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A four-part webinar series.

Start Time:12:00 AM
End Time:12:00 AM
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Additional Information

Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, Jan. 24
9 - 11 a.m.

Register on or before Wednesday, Jan. 16, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation. This webinar also is eligible for use of the MHA Health Institute coupon. Coupons were mailed to MHA-member hospital CEOs on Dec. 17.


anyone involved with compliance regulations and standards, including but not limited to, CEOs, CFOs, CMOs, CNOs, physicians, nurses, quality improvement staff, risk managers, pharmacy staff, dieticians, compliance officers and legal counsel, ethics committee members, consumer advocates, TJC liaisons, safety officers, behavioral health and psychiatric staff, case managers, and other interested staff

The following program content was provided by the speaker.


Critical access hospitals must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation. CMS regulations and interpretive guidelines serve as the basis for determining compliance. In this four-part webinar series, participants will learn CoPs details of what to do when a surveyor arrives at their facility. Additionally, every section in the CAH hospital manual will be discussed. This includes updates and 2019 proposed changes added in October 2018.

Part I of this four-part webinar series will provide an introduction to CMS, including 2019 proposed changes, and CMS memos on topics such as safe injection practices, deficiencies, the revised complaint manual, texting, ligature risks, and more. CAH problematic standards will be reviewed and resources will be provided. The speaker will discuss the various regulations and interpretive guidelines for CAHs, including but not limited to, compliance, licensure, provider certification, network agreements, credentialing, advanced directives, ED staffing, EMTALA, equipment and supplies, medication, personnel, emergency response, length of stay, observation (two-midnight rule), swing beds, and numbers of beds.


  • describe the CMS requirement in which the board must enter into a written agreement if the hospital wants to enter into telemedicine services
  • discuss the CMS list of emergency drugs and emergency equipment that every CAH must have
  • explain how the length of stay in a CAH should not exceed 96 hours on an annual average basis
  • discuss recommendations to do a gap analysis to ensure compliance with all hospital CoPs


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians and other health care providers. Dill Calloway has authored more than 100 books and numerous articles. She is a frequent speaker and is well known across the country in the area of health care law, risk management and patient safety.