Critical Access Hospital Conditions of Participation 3-Part Webinar Series

From May 2 2024 12:00 pm until May 16 2024 2:00 pm
At Webinar

Recording of sessions will available to those that cannot attend the live session.   

This three-part webinar series will provide an overview of the Critical Access Hospital (CAH) Conditions of Participation (CoP) regulations, interpretative guidelines and related Quality, Safety and Oversight Letters to State Survey Agencies. There have been many new regulations and interpretative guidelines that have been promulgated for critical access hospitals over the last few years. This series will assist in efforts to comply with challenging new areas, patient rights, infection prevention and antibiotic stewardship emergency preparedness, QAPI and other commonly cited areas of non-compliance.

Instructor: Nancy Ruzicka, Ruzicka Healthcare Consulting, LLC

Target Audience: This program is intended for all critical access hospitals (CAH) staff  and anyone involved with  compliance regulations and standards, including but not limited to CEO, CNO, other C-suite staff, nurse managers, quality improvement staff, risk managers, compliance officers and legal counsel, Joint Commission  or DNV liaisons, safety officers, CAH network liaisons, infection preventionists, facility staff, department managers, and other interested staff, including front line nursing staff.

  • Handouts will be shared prior to each webinar
  • The recording link for each session will be available to all registrants for 60 days

May 2, 2024 12:00 - 2:00 pm - Session 1
Compliance with Federal, State & Local Regulations, Location, Emergency Services, Beds &Length of Stay, Physical Environment & Emergency Preparedness

  • CMS expectations for physician, providers & telemedicine providers credentialing including external peer review
  • Required notifications to State Survey Agency and CMS
  • Types of emergency equipment and drugs that every CAH must have
  • Average length of stay requirements
  • Relocation and off-site premise requirements
  • Physical plant requirements
  • Emergency preparedness requirements including planning 

May 9 2024 12:00 - 2:00 pm - Session 2
Organizational Structure, Staffing and Staff Responsibilities, Provision of Services (which includes nursing, pharmaceutical, laboratory, radiology and rehabilitation service standards), clinical records and surgical services.

  • Physician and mid-level practitioner responsibilities & staffing requirements
  • Pharmacists’ responsibilities from procurement to dispensing drugs and biologicals
  • Medication administration requirements including self-administration
  • Plan of care requirements
  • Minimum informed consent elements
  • History and physical examination requirements
  • Operative report elements
  • Surgical and anesthesia documentation requirements

May 16, 2024 12:00 - 2:00 pm - Session 3 
Infection Prevention and Antibiotic Stewardship, Quality Assessment and Performance Improvement, Discharge Planning and Swingbed Services

  • CMS minimum standards for infection prevention program
  • Antibiotic stewardship program
  • Requirements of a QAPI program
  • New requirements for Patient Rights in CAH for all patients
  • Minimum requirements for discharge planning
  • Basic requirements of swing-bed program

 Continuing Education:  Clock Hours:  2.0 per session

Application is being made to the following agencies: MN Board of Nursing, MN Board of Social Work., & MN Board of Pharmacy. The # of CEU’s will be indicated on the certificate of attendance provided to each participant who attends the session.  To check on final hours awarded, please contact the Medi-Sota office.

Registration Fees

Medi-Sota Members: $299 Per Hospital (Not System) for entire 3-part series                      

Non-Medi-Sota Members: $499 Per Hospital for the 3-part series

  • 1 Registration Fee per hospital (not health system)
  • No extra charges for multiple connection lines.
  • All participating individuals should register for the workshop, but each facility will receive only one invoice from Medi-Sota following the first webinar attended by individuals from that organization. All registered individuals will be provided connection information and handouts.  If there are any duplicate payments made, the facility will be refunded.  Please choose only 1 ticket and then choose Mail Invoice.  
  • The recording link for each session will be available to all registrants for 60 days.

Prior to the program, you will receive an email with any additional course information. Registration Deadline: May 1, 2024 by 5pm this ensures all registrants will receive course information & any materials in a timely manner.

Cancellations must be made no later than 10 business days prior to the start of the course. The full course fee will be charged if cancellation is made in less than 10 business days. Full refunds will be given for all classes cancelled by Medi-Sota. Registration is transferable to another person.

An alliance of rural healthcare organizations working together to provide customized value and services that will meet the individual needs of its members.

Contact Information


1280 Locust Street, Suite 16
Dawson, MN 56232

(320) 769-2269