There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some of which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control, antibiotic stewardship, QAPI, and Discharge Planning.

This part of the series will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and storage, and informed consent, among others.

CAH Conditions of Participation 2026 – Part 1 || Day 1

Introduction, General Information, Memos, Distinct Units, Advance Directives, Required Disclosures, Number of Beds, Length of Stay, and Observation Status

Learning Objectives:

• Describe how to find the manual and updates
• Describe what to expect with a survey
• Describe required disclosures for a CAH
• Recall what is included inthe  25-bed maximum count
• Recall that the average length of stay in a CAH should not exceed 96 hours on an annual basis

CAH Conditions of Participation 2026 – Part 2 || Day 2

Advance Directives, Patient Rights Part 1: Notice to patient, Consent, Disclosures, Advance Directives, Visitation, Grievances, Privacy, Swing Bed patients, and Interpreters

Learning Objectives:

• Describe the various patient rights to include providing consent, forming advance directives, and visitation rights
• Describe the need for a hospital to have a grievance policy and procedure in place
• Describe required disclosures for a CAH
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment

CAH Conditions of Participation 2026 – Part 3 || Day 3

Patient Rights Part 2: Safety, Ligature Risks, Abuse and Neglect, Restraint and Seclusion

Learning Objectives:

• Describe the various ligature risks CMS has identified and how hospitals need to assess patients and the environment for risks to patients from ligature harm
• Describe the reporting requirement a hospital must complete when patient abuse is suspected
• Recall that CMS has restraint standards that hospitals must follow

CAH Conditions of Participation 2026 – Part 4 || Day 4

Emergency Services, Staffing and Responsibilities, Provision of Services, Emergency Procedures and EMTALA

Learning Objectives:

• Describe staffing requirements and supervision
• Recall the required14 emergency department written policies that must be present
• Describe that CMS has a list of emergency drugs and equipment every CAH must have
• Recall that a CAH must comply with EMTALA requirements
• Describe the new Condition of Participation for obstetrical services, es including required staff training, equipment, ent and provisions, equipment, and organization.