Part 1: Introduction, Memos, Compliance, Agreements, Contracts, Board Duties, Emergency Services, Observation and Physical Environment - Tuesday, Jan. 19

Part 2: Provision of Services: Nursing, Pharmacy, Dietary, Drugs and Equipment, Surgery, Anesthesia and ED - Tuesday, Jan. 26

Part 3: Infection Control, Safe Medication, Lab, Patient Services, Outpatient and Discharge Planning - Tuesday, Feb. 2

Part 4: Radiology, Organ Procurement, Rehab, Visitation, Medical Records, QAPI and Swing Beds - Tuesday, Feb. 9

Part 5: CMS Hospital QAPI for CAHs - Tuesday, Feb. 16

All sessions 9 to 11 a.m., CST


This five-part webinar series will cover the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) for critical access hospitals (CAHs).

The series will discuss recent changes to requirements for discharge planning; antibiotic stewardship; medical records, quality and performance improvement (QAPI); infection control; emergency preparedness; policy review; dietician credentialing; diagnosis quality and appropriateness; swing beds; life safety codes; and facility services. It will cover updates for COVID-19 reporting that impact hospitals, laboratories and nursing homes and review recently issued hospital memos. Participants will learn about common deficiencies and how to do a gap analysis to increase compliance.


Laura A. Dixon, B.S., J.D., RN, CPHRM

Laura A. Dixon served as the director, facility patient safety and risk management and operations, for COPIC, a medical liability insurance agency, from 2014 to 2020. In her role, Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of health care facilities and development of programs and compilation of reference materials that complement physician-oriented products.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services and pain management. Prior to joining COPIC, she served as the director, western region, patient safety and risk management, for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to physicians and staff for the western United States. 

Who should attend

Anyone responsible for their organizations’ compliance with CMS regulations. 

Continuing education

Each session in the webinar series has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 1 contact hour.

Learning objectives

Part 1:

  • Describe how to find information on CMS regulations
  • Recall the process to identify common deficiencies cited by CMS
  • Discuss recommendations to do a gap analysis to ensure compliance with the hospital CoPs
  • Identify changes to CMS CoP manual within the last three years

Part 2:

  • Explain the responsibilities of pharmacists, including developing, supervising and coordinating pharmacy activities
  • Describe the requirements for CAHs to ensure that outdated drugs are not available for patient use
  • Recall the requirements for security and storage of medications, medication carts and anesthesia carts
  • Recall the requirements for nursing services, order sets and protocols
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound-alike/look-alike drugs

Part 3:

  • Recall that the infection preventionist must be appointed by the board
  • Recall that CMS has an infection control worksheet that may be helpful to CAHs
  • Discuss proper usage of insulin pens
  • Describe that an order is needed to allow the patient to self-administer medications
  • Explain that there are three time frames in which to administer medications
  • Discuss what CMS requires for discharge planning

Part 4:

  • Explain the informed consent elements required by CMS
  • Describe the requirements for history and physicals for CAHs
  • List what must be contained in the operative report
  • Discuss what CAHs must do to comply with requirements for notification of organ procurement agencies
  • Recall that CMS has many patient rights that are afforded to patients in swing beds
  • Recall that hospitals must have a visitation policy and patients must be informed 

Part 5:

  • Recall that CMS has a worksheet on QAPI
  • Recall that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Discuss the rewritten QAPI requirements CMS implemented for CAHs
  • Discuss that the board is ultimately responsible for the QAPI program and must ensure there are adequate resources
  • Recall that hospitals are receiving a high number of deficiencies in QAPI


  • $200 per session for MHA member hospitals and health systems
  • $300 per session per organization for nonmembers

In order to allow for social distancing, pricing is set up per hospital rather than per connection. Please register just one person from your facility and have that person share the access information with others within your facility who wish to participate. Each hospital within a system must register separately.

Registration deadline

Please register by 5 p.m. two business days before each session to ensure timely delivery of access instructions.

Approximately four business days before each session in the webinar series, you will receive an email that contains instructions on how to connect. Advance registration is required to ensure delivery of instructional materials.

If you do not receive an email from Christy Hammer prior to the program with web conference details, please contact to confirm your registration.

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When and Where
  • 1/19/2021 9:00 AM CST
  • 2/16/2021 11:00 AM CST
  • Web Conference