CAH CoPs 2019: Ensuring Compliance — Part III 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, Feb. 7
9 - 11 a.m.

Register on or before Wednesday, Jan. 30, 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.


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.

During part III of this four-part webinar series, our speaker will review 2015 manual revisions for the sections on infection control, drugs and safe medication use, patient services, lab, and nursing. She will discuss nationally recognized infection control guidelines, including hospital acquired infections, the four challenges of infection control, the role of hospitals leaders in infection control, and why the infection control worksheet is so important for CAHs. Safe medication CoPs, including preparation and administration, safe infection practices, and the CMS IC worksheet and safe infection guidelines, will be outlined. A review of the nursing CoPs will cover nursing care, changes in observation guidelines, drugs and IVs, nursing care plans, and proposed changes for 2019.


  • discuss how the CMS infection control worksheet may be helpful to CAHs
  • explain how many times an insulin pen may be used on patients
  • define what is needed to allow the patient to self-administer medications
  • identify the timeframes in which to administer medications
  • describe the CMS requirement for a plan of care


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.