Critical Access Hospital Conditions of Participation: July 25

Date: July 25, 2025 Time: 9:30 AM

Location:

5-part webinar series
9:30 – 11:30 a.m. ꟾ July 25, August 1, 8, 15 and 22  

Registration:

Health System Registration
IHA offers a “Health System” registration to accommodate systems enrolling multiple hospitals and offsite offices. To register as a Health System, choose the “Health System” option when registering.

 Registration Option  IHA Member Fee (per webinar)  Non-Member Fee (per webinar)
 Hospital Registration  $195  $395
 Health System Registration  $395  $795


Hospital Registration
Applies to a single hospital location. All internal units and departments at that location may participate under one registration.

Example: Hospital A selects Hospital Registration and provides access to its own departments only. Affiliates or other facilities may not use this registration.

Health System Registration
Applies to an entire health system, including corporate offices and all affiliated hospitals. All units and departments within the registered system may participate.

Example: Health System B selects Health System Registration and provides access to every affiliated hospital and its corporate teams.

Register Online

The Centers for Medicare & Medicaid Services (CMS) continuously revises its Conditions of Participation (CoPs), 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 ever-shifting survey protocols and interpretive guidelines.

In healthcare, change never stops. Your compliance strategy must continually evolve to keep pace with new regulations and the latest standards of care.

This five-part webinar series is built specifically for CAH leaders and staff. Led by nationally-recognized regulatory expert Nancy Ruzicka, B.S., RPh, MBA, MJ, CHC, , this series will walk you through what’s required, what’s new and where CAHs are most at risk.

Why Attend?
Whether you’re managing Patient Rights compliance, preparing for a swing bed review, or tightening your infection control protocols, this program will give you the knowledge, tools and confidence to lead your next survey with certainty. You’ll receive practical compliance strategies tailored for CAHs, with each of the five sessions offering insights into the most commonly cited deficiencies in Illinois and across the country.

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

  • Medication Administration

  • Emergency Preparedness

  • Swing Bed Services

Regulatory changes and upcoming revisions:

  • Emergency Services and Transfers for Obstetrical Emergencies (2025)

  • Patient Rights

  • Infection Prevention Program

  • Antibiotic Stewardship Program

  • Quality Assessment and Performance Improvement (QAPI)

  • Updated Swing Bed Requirements (including Appendix PP tags)

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

Agenda

Part 1: This session will focus on the provision of emergency services, CMS expectations for observation status, unique characteristics of a critical access hospital and available resources and methods to maintain current knowledge of the regulations.

Webinar Topics

  • General Information

  • Memos

  • Recent Regulatory and Interpretative Guideline Changes

  • Emergency Services

  • Observation Status

  • Most Frequently Cited Deficiencies

Objectives

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

  • Describe minimum standards for provision of emergency services.

  • Explain average length of stay requirements and bed requirements.

  • Discuss recommendations to do a gap analysis to ensure compliance with all hospital CoPs.

Who Should Attend

The series will benefit CAH leaders and staff responsible for the following:

  • 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

Speakers

Nancy M. Ruzicka B.S., RPh., MBA, MJ, CHC
Nancy is a recognized expert on state and federal rules, regulations and interpretative guidelines. She is the owner of Ruzicka Healthcare Consulting and provides consultation to individual client hospitals, nursing facilities, rural health clinics, physician offices and other Medicare certified healthcare providers through both onsite mock surveys, remote consultation and interpretation of Medicare Conditions of Participation. She also provides education on federal regulations throughout the nation to multiple state hospital associations including the Minnesota Hospital Association, Iowa Hospital Association, Missouri Hospital Association, Texas Hospital Association and South Dakota Association of Healthcare Organization. She has also served as content expert and editor for regulatory client hospital education for Lammico, a medical malpractice insurance company.

Previously Nancy worked as Director of Integrity and Compliance and Privacy Official at Mercy Medical Center-Des Moines and Director of Regulatory Compliance at UnityPoint Health, Des Moines. She also has more than 20 years of experience with the Iowa Department of Inspections and Appeals. While working for the State of Iowa, she surveyed all types of types of organizations including hospitals, critical access hospitals, psychiatric hospitals, intermediate care facilities for developmentally disabled, nursing homes and other Medicare certified entities. She was also responsible for updating state hospital licensing regulations which had not been updated since the early 1970s. 

Nancy holds master’s degrees in health law and business administration and a bachelor’s degree in pharmacy, all from Drake University. She is certified in health care compliance and maintains her Iowa pharmacy license. 

Register online