Registration fees for webinars are $175/member and $300/non-member unless otherwise noted in an event description.

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

CAH Conditions of Participation 2021: Part 1 of 5

Date: 01/19/2021

9:00 AM - 11:00 AM

Part 1 of 5: Introduction, Memos, Compliance, Agreements, Contracts, Board Duties, Emergency Services, Observation and Physical Environment

This is a four-part webinar series, plus a detailed webinar on QAPI for a total of 5 total webinars. However, you can register for only specific webinars if you choose. See registration pricing below.

Registration fees are $500 per facility for ALL 5 webinars; or $175 per facility per webinar if not registering for all 5.  If registering for all 5 webinars, please email your registrant names & email addresses to Pam at You do not have to register 5 times through each of the online links.

Suggested Audience: CEOs, COOs, CFOs, nurse executives, accreditation and regulation director, nurse managers, pharmacists, quality managers, risk managers, healthcare attorneys, health information management personnel, social workers, dieticians, health information management,  nurses, nurse educators, nursing supervisors, patient safety officer, infection preventionist, radiology director, laboratory director, emergency department directors, outpatient director, medication team, ethicist, director of Rehab (OT, PT, speech pathology, and audiology), OR supervisor, OR staff, CRNA,  anesthesia providers,  dietician, radiology staff, director of health information management, infection preventionist, dietician, activities director of swing bed patients, infection control committee members, pharmacists, and compliance officers.

Objectives - At the conclusion of part one, participants should be able to:

  • Describe the method 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 all the hospital CoPs
  • Identify changes to CMS CoP manual within the last 3 years


  • History
  • How to find CMS manuals, survey memos and changes
  • CAH problematic standards
  • CMS websites and CAH Resources
  • Conditions of participation

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

Overview of CAH

  • Basis and scope
  • Rural Health Network
  • Personnel Qualifications
  • Designation and Certification of CAHs

Agreements and Organization Structure and Board Duties

  • Personnel Qualifications
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Status and Location
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Governing Body
  • Staffing and Responsibilities
  • Physician responsibilities
  • Transfer of patient
  • Patient admissions
  • Medical management
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality
  • Agreements for Telemedicine

Emergency Services and Observation

  • Emergency Services
  • ED staffing
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Number of Beds and Length of Stay
  • Observation, two midnight rule
  • Number of Beds
  • Length of Stay

Physical Environment

  • Physical Plant and Environment
  • Maintenance and equipment
  • Disposal of trash
  • Storage of drugs and biologicals
  • Physical environment and ventilation
  • Construction and equipment
  • Life Safety from Fire
  • LSC waivers
  • Fire inspections
  • Emergency Preparedness – also in Appendix Z

SPEAKER: Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. 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 healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.