Events

Swing beds can be a financial lifeline for Critical Access Hospitals (CAH). This webinar will focus on swing bed regulations in Appendix W for CAHs. Swing bed common deficiencies and how to avoid them will also be reviewed.

While it can be challenging to determine the interpretive guidelines and survey procedures without a crosswalk between Appendix W and Appendix PP, this webinar will assist hospitals in understanding what actions need to be taken.

Date
Jul. 29, 2025
Time
8:00 am - 9:30 am
Virtual
Certified Nurse Aide
Clinical Education
Clinical Operations
Compliance
Human Resources
Quality & Safety

This webinar will discuss Section 1557 of the Affordable Care Act, which applies to all hospitals (including Critical Access Hospitals (CAH)) and other healthcare providers such as physician offices and nursing homes. The law addresses nondiscrimination, required signs and notices, interpreters, a civil rights law for healthcare providers, and more. Section 1557 forbids discrimination based on sex, race, color, national origin, age, and disability and is the first law to prohibit discrimination based on sex in covered health programs and activities.

This program will discuss case law regarding several issues of importance to hospitals and changes by the Office of Civil Rights (OCR).

Attendees will also learn about the Centers for Medicare & Medicaid Services (CMS) recognition that there were no prohibitions in the hospital Conditions of Participation (CoPs) on gender identities, which can be a barrier to seeking care. While CMS decided not to include the law in two separate places within the CoPs, CMS can refer any issue to the OCR.

This program will provide resources and information to help meet the education requirements to ensure your employees understand and abide by this law.

Date
Jul. 15, 2025
Time
8:00 am - 9:30 am
Virtual
Clinical Operations
Compliance
Human Resources
Leadership
Quality & Safety

This program will cover the changes to the discharge planning standards published in February 2020. The Centers for Medicare & Medicaid Services (CMS) has yet to publish revised interpretive guidelines and survey procedures to match the new regulations. The regulations apply to all hospitals, including Critical Access Hospitals (CAHs).

This webinar will also discuss the Impact Act’s effects on hospital discharge planning. The Act requires hospitals to assist patients with post-discharge care, whether they are using at home health or are transferred to a skilled nursing facility, long-term care hospital, or inpatient rehab facility. Information on all four must be provided to the patients except for CAHs.

This program will address transfers to other facilities, assessment of readmission within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more.

Date
Jul. 10, 2025
Time
8:00 am - 9:30 am
Virtual
Behavioral Health
Certified Nurse Aide
Clinical Education
Clinical Operations
Community Health Worker
Compliance
Nursing Education
Quality & Safety

This series will review the components of an effective infection prevention program and connect the dots among program planning, implementation, and patient outcomes. Our speaker will discuss the annual evaluation, risk assessment, and program plan, including methods to evaluate your data, set priorities, and engage stakeholders. Attendees will also learn about the important roles of construction, renovation, cleaning, and disinfecting in preventing infections.

Date
Jun. 25, 2025 - Jun. 26, 2025
Time
8:00 am - 10:00 am
Virtual
Certified Nurse Aide
Clinical Education
Clinical Operations
Community Health Worker
Compliance
Home Health & Hospice
Long-Term Care
Nursing Education
Quality & Safety
This program will detail the Centers for Medicare & Medicaid Services (CMS) regulations and interpretive guidelines for medical records for acute care and critical access hospitals. The Interoperability and Patient Access Rule, which grants patients access to health information in their electronic medical record without charge, will be discussed.
This session will also cover the Health Insurance Portability and Accountability Act (HIPAA) from the Office of Civil Rights (OCR). Attendees will learn the difference between patient access and when an authorization is needed. Other topics to be discussed include security of health information and the OCR Security Risk Assessment.
Date
Jun. 24, 2025
Time
8:00 am - 9:30 am
Virtual
Clinical Education
Clinical Operations
Compliance
Quality & Safety
Workplace violence has escalated over the past 15 years, especially in the healthcare arena. Providers and staff, as well as family members and bystanders (including other healthcare providers) frequently experience this violence.
In November 2022, the Centers for Medicare & Medicaid Services (CMS), issued a memo regarding workplace safety addressing care in a safe environment. This program will cover the CMS standards for workplace safety and emergency preparedness standards.
Date
Jun. 10, 2025
Time
8:00 am - 9:30 am
Virtual
Clinical Education
Clinical Operations
Community Health Worker
Compliance
Leadership
Preparedness & Response
Quality & Safety
The first session in the series will cover the components of a robust workplace violence prevention program. Participants will learn how to conduct risk assessments, establish reporting mechanisms, implement evidence-based training, and foster a culture of safety. The webinar will explore the integration of security protocols, staff education, and incident response strategies. Attendees will learn how to build and sustain an effective violence prevention program tailored to their healthcare environment.
Part two of the series will cover workplace violence risk assessments. Attendees will learn how to identify high-risk areas, analyze incident data, and evaluate existing security measures. The webinar will discuss how to pinpoint vulnerabilities, prioritize threats, and use assessment findings to inform policy updates, staff training, and facility design improvements.
The third session will describe the skills needed to effectively de-escalate potentially violent situations. Attendees will learn to recognize behavioral cues, apply verbal and non-verbal communication techniques, and use situational awareness to prevent escalation. The webinar will also cover how to maintain personal safety, set boundaries, and foster a calm environment.
The fourth session will explore how healthcare facilities can enhance workplace violence prevention and response efforts. Attendees will discover innovative tools such as real-time location systems (RTLS), panic buttons, video surveillance, and access control systems. The webinar will highlight how these technologies can streamline incident reporting, improve threat detection, and support faster emergency response.
The final session will focus on fostering psychological safety and providing meaningful support for healthcare staff in the aftermath of workplace violence. Attendees will learn strategies for post-incident debriefing, trauma-informed care, and peer support programs. The webinar will also cover the role of leadership in cultivating a culture where employees feel safe reporting incidents and accessing mental health resources.
Date
May. 15, 2025 - Jun. 12, 2025
Time
11:00 am - 12:30 pm
Virtual
Clinical Education
Clinical Operations
Community Health Worker
Leadership
Preparedness & Response
Quality & Safety

The Centers for Medicare & Medicaid Services (CMS) has issued many citations related to the governing board, specifically contract management. The governing board of a hospital oversees contracted services and ensures compliance with standards set forth by accrediting bodies. This presentation will cover all contract requirements for hospitals under the CMS Conditions of Participation.

Virtual
Clinical Education
Clinical Operations
Compliance
Data & Analytics
Leadership
Quality & Safety

Any hospital that accepts Medicare reimbursement must comply with the Centers & Medicaid Services (CMS) Conditions of Participation (CoPs). The patient rights CMS CoPs manual has the highest number of deficiencies for hospitals.

This webinar will cover the CoPs Appendix A section on patient rights, which applies to hospitals. Critical Access Hospital (CAH) Appendix W does not have a similar section. CAHs must provide a safe environment for patients.

Topics covered in this session include grievances, right to receive notice exercise of rights, informed consent, privacy, confidentially of medical records, directives, interpreters, abuse and neglect, plan of care, visitation rules, and support rights.

After this session, participants should be able to:
  • Identify that the CMS regulations regarding grievances require hospitals to have a grievance committee.
  • Recall that CMS has requirements for advance directives.
  • Discuss the CMS requirement for providing patients and/or their representatives information on patient rights.
  • Explain the various requirements regarding restraints and/or seclusion.
Date
Mar. 18, 2025
Time
8:00 am - 9:30 am
Location
Zoom
Virtual
Clinical Education
Clinical Operations
Compliance

Any hospital that accepts Medicare and Medicaid payments must comply with regulations known as the Conditions of Participation (CoPs). The Centers for Medicare & Medicaid Services (CMS) hospital CoPs have sections on all aspects of patient care, including medical staff and telemedicine.

This webinar will discuss the governing body and medical staff sections of the CoPs manual in relation to requirements and oversight. Although telemedicine has been a factor in health care (healthcare) for many years, COVID-19 has given it a larger role in the diagnosis and treatment of patients. This session will discuss standards for acute care hospitals, Critical Access Hospitals (CAHs), and Rural Emergency Hospitals (REHs) participating in telemedicine. Finally, attendees will learn what provisions should be included in a telemedicine contract.

After this session, participants should be able to:

  • Recall that hospitals can have a separate medical staff or a unified shared integrated medical staff.
  • Explain the overlap between the governing body and medical staff.
  • Describe the requirements for a medical staff under the CMS Conditions of Participation.
  • Discuss the requirement that hospitals must have a written telemedicine agreement specifying the responsibilities of the distant-site hospital and entities to meet the credentialing requirements.
Date
Mar. 4, 2025
Time
8:00 am - 9:30 am
Location
Zoom
Virtual
Clinical Operations
Compliance
Quality & Safety
Workforce

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