NEW FOR 2026: SAME COMPREHENSIVE CONTENT, FEWER SESSIONS

Previously delivered in five two-hour webinars, the full 10-hour curriculum is now offered as a three-part intensive webinar series. You’ll receive the same content in fewer sessions, with related topics grouped together for an integrated learning experience.



PROGRAM OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) revises its Conditions of Participation (CoPs) regularly, challenging hospitals to adapt their processes to keep pace with evolving regulations and avoid costly citations. For Critical Access Hospitals (CAH), staying in compliance means mastering a 300-plus page State Operations Manual, absorbing constant updates from CMS, and navigating new survey protocols and interpretive guidelines. Your hospital’s compliance strategy must continually evolve to keep pace with new regulations and the latest standards of care.

Over the past year, CMS has updated CAH regulations and guidelines in several key areas, including emergency preparedness, nutritional services and care for obstetrical patients, even at CAHs without organized obstetrical services. Although the CAH manual does not include a dedicated Patient Rights section, CAHs must still maintain a safe care environment and uphold all patient rights.

This series will address recent regulatory changes affecting infection prevention and control, Quality Assurance and Performance Improvement, and discharge planning, as well as requirements that lack interpretive guidelines. You’ll also examine key compliance requirements related to nursing care plans, medication management, informed consent, and required policies and procedures.

Nationally recognized regulatory expert Nancy Ruzicka, BS, RPh, MBA, MJ, CHC, will lead this 10-hour intensive webinar series designed for CAH leaders and staff. Across three sessions, Ruzicka will walk you through what’s required, what’s new and where CAHs may be most at risk.

Why Attend?

Maintain compliance and minimize your risk of survey citations. Attend to learn the latest CMS requirements and stay survey ready.

Whether you’re managing patient rights compliance, preparing for a routine recertification survey, or dealing with an unexpected complaint investigation, this program will give you the knowledge, tools, and confidence to lead your next survey or handle your next unexpected complaint investigation with certainty. You’ll receive practical compliance strategies tailored for CAHs, with each of the three sessions offering insights into the most commonly cited deficiencies in Illinois and across the nation.
What You’ll Learn

Each session will provide a deep dive into the full CAH manual, focusing on:

Frequently cited CoPs in Illinois CAHs:

  • Patient Rights, including restraint use
  • Physical Environment including Life Safety Code and Maintenance
  • Emergency Preparedness
  • Swing Bed Services

Regulatory changes and upcoming revisions:

  • Emergency Services and Transfers for Obstetrical Emergencies (2025-2027)
  • Patient Rights
  • Nutritional Services
  • Infection Prevention Program
  • Antibiotic Stewardship Program
  • Quality Assessment and Performance Improvement (QAPI)
  • Updated Swing Bed Requirements (including Appendix PP tags)


WEBINAR TOPICS

October 23

Part 1: Introduction, General Information, Memos, Recent Regulatory and Interpretative Guideline Changes, Emergency Services, Observation Status, and overview of most frequently cited deficiencies in Illinois CAHs

Part 2: Physical Plant and Environment, Emergency Preparedness, Governing Board and Organizational Structure

 

October 30

Part 1: Nursing Services, Laboratory Services, Pharmaceutical Services, Radiologic Services, Rehabilitation Services, Infection Prevention and Control, and Antibiotic Stewardship

Part 2 Medical Records, Surgical Services, Organ Procurement and Swing Beds


November 6

QAPI, Discharge Planning and Patient Rights

 
WHO SHOULD ATTEND

The series will benefit CAH leaders and staff organization-wide:

  • Hospital administration (CEOs, COOs, CMOs, CNOs) 
  • Compliance, accreditation and regulation
  • Quality improvement 
  • Risk management
  • Facility management
  • Infection preventionists and infection prevention committee members
  • Healthcare attorneys
  • Health information management
  • Directors of radiology, laboratory, emergency department, outpatient care, rehabilitation (OT, PT, speech pathology and audiology) and operating room
  • Clinical leaders including physicians, nurses, pharmacists, social workers and dieticians