CAH CoPs 2019: Ensuring Compliance — Part II 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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Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, Jan. 31
9 - 11 a.m.

Register on or before Wednesday, Jan. 23, 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.

In part II of this four-part webinar series, pharmacist responsibilities, including development, supervision and coordination of pharmacy activities, will be described. The speaker will review CAH requirements to monitor and inspect, then ensure outdated drugs are not available for patient use. Requirements will be reviewed for security and storage of medications, medication carts and anesthesia carts, as well as do-not-use list of abbreviations and sound-alike/look-alike drugs. There will be an examination of various changes to the CoPs, including but not limited to, dietary and nutrition services, physical plant and environment, maintenance, fire inspections staffing, physician responsibilities and supervision, and patient admissions and transfers.


  • explain the pharmacist's responsibilities with regard to developing, coordinating and supervising pharmacy activities
  • list the CAH requirements that prevent patient use of outdated drugs
  • discuss the requirements for security and storage of medications, medication carts and anesthesia carts
  • identify the requirements to have a do-not-use list of abbreviations, and review of sound-alike/look-alike drugs


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.