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The CMS Hospital Conditions of Participation (CoPs) for Acute Hospitals

January 21 @ 8:00 am - 10:00 am MST


Multi-part webinar series | Part 1 – Jan. 21; Part 2 – Jan. 28; Part 3 – Feb. 4; Part 4 – Feb. 11; and Part 5 – Feb. 18

Due to COVID-19, the registration is per hospital and not per connection for this webinar series. A single registration provides unlimited lines for employees of your hospital, including a link to view the recording. Please only select a qty. of “1” under Registration and indicate the number of connections requested when completing the Attendee information. This person will be responsible for sharing the access information with others who wish to participate.

Not sure if you’ll be able to make the live session? Everyone who registers will receive a link to the recording of the webinar to view at your convenience at no additional charge for 60 days post-webinar.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. The manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital owned departments. Facilities accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV GL Healthcare with Deemed Status must follow these regulations. 

This five-part webinar series will cover the entire CMS Hospital CoP manual for acute hospitals. This program will discuss the most problematic standards and how the hospital can do a gap analysis to assist in compliance with the CoPs.

This program will cover the over 500 pages of the State Operations Manual for Acute hospitals.  Each section of the manual will be discussed including those which had recent updates and still-pending Interpretive Guidelines.

The interpretive guidelines serve as the basis for determining hospital compliance and there have been many changes in the recent years. There have been significant changes and many important survey memos issued also. CMS issued the final surveyor worksheets for assessing compliance with the QAPI, infection control and discharge planning standards. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance.

Part 1 of 5: Introduction, CMS Survey Memos, Surveyor Training Material, Hospital deficiency reports, CMS 3 worksheets, CDC Vaccine, OCR 1557, Required Education, Hard Hit Areas, Board and Medical Staff, Budget, Contracts, Emergency Services, Medical Records, Standing Orders, H&Ps


  • Discuss how to locate a copy of the current CMS CoP manual
  • Describe that a history and physical for a patient undergoing an elective surgery must not be older than 30 days and updated the day of surgery
  • Discuss that verbal orders must be signed off by the physician along with a date and TIME

The agenda will cover:

Overview of the CMS Survey Process and Introduction

  • Introduction
  • Recent revisions
  • Hospital revised worksheets; infection control, PI, and discharge planning
  • CMS required education
  • Survey process
  • Compliance with law
  • Order sets, protocols, standing orders

Board and CEO

  • Board requirements
  • CMS by-laws
  • Credentialing and privileges
  • Medical staff and the board
  • Single medical staff or unified integrated MS
  • Privileging others such as PharmD, podiatrist, RD, etc.
  • Telemedicine
  • CEO requirements
  • Care of patients
  • Plan and budget
  • Contracted services
  • Emergency services
  • Autopsy changes
  • Board responsibilities for infection control and QAPI if chooses system wide

Medical Records (Health Information Management)

  • Access to medical records update and new penalties
  • Final drug and alcohol federal law (substance use disorder records)
  • Organization and staffing
  • Confidentiality of records
  • Content of records
  • Legibility requirements
  • Authentication
  • Informed consent mandatory and optional elements
  • H&P and changes for healthy outpatients
  • Verbal orders
  • Signature stamps and guidelines
  • Discharge summary
  • Recent changes to access rules

 Part 2 of 5: Patient Rights: Advance Directives, Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, Restraints and Visitation


  • Recall that CMS has restraint standards that hospitals must follow
  • Describe that the patient has a right to file a grievance and the hospital must have a grievance policy and procedure in place
  • Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical record
  • Discuss the patients’ rights regarding Advanced Directives

Patient Rights

  • Final changes
  • Most problematic standards for hospitals
  • Penalties for not giving patients timely access to their medical records
  • Safety of behavioral health patients and ligature risks
    • Right to privacy and safety
    • OCR Section 1557
    • Right to an IM Notice for Medicare patients
    • Interpreters
    • Low health literacy
    • Advance directives
    • Informed consent
    • Abuse and neglect
    • Criminal background checks
    • Grievances and complaints (TJC)
    • Visitation requirement
    • Plan of care
    • Informed consent
    • Advance directives
    • Care in a safe setting
    • Patient medical records
    • Access to medical records
    • Restraint and seclusion-high number of deficiencies for hospitals
    • Visitation

Part 3 of 5: Nursing and Pharmacy


  • Describe that medications must be given timely and within one of three blocks of time
  • Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
  • Recall that there are many pharmacy policies required by CMS
  • Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
  • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

 Nursing Services

  • Final changes
  • Nurse at bedside
  • Approval of infection preventionist
  • Duties of the Director of nursing (CNO)
  • Medication administration and safe opioid use
  • Safe injection practices and compounding
  • Staffing
  • Policies and procedures
  • Nursing care plan
  • Staff competency
  • Preparation and administration of drugs
  • Self-administration of medication
  • IV and blood transfusions
  • Reporting medication errors and ADEs
  • Three Timing Rules of medication
  • Orders, protocols, standing orders, order sets
  • IV medication and blood transfusions
  • Incident reports

Pharmaceutical Services

  • Final antibiotic stewardship program requirements
  • Revised CDC core for ASP
  • BUD, compounding and more
  • Administration of medication within the BUD from preparation of CSP and change
  • Compounding pharmacy and amended nursing tag 405
  • Pharmacy administration and must meet needs of patients
  • Standardization of prescribing and communication practices
  • Drugs and biological
  • High-risk medication
  • Definitions of medication errors, ADE and DI
  • Notification of physician
  • Pharmacy requirements
  • Storage and security of medications
  • Outdated or mislabeled medications or unusable drugs
  • Drug interactions and side effects
  • PI requirements for adverse drug events

Part 4 of 5: QAPI, Medical Staff, Dietary, Radiology, Lab, Utilization Review, and Facility Services


  • Recall that CMS has patient safety requirements in the QAPI section that are problematic standards
  • Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified
  • Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state

Medical Staff, Board, and CEO

  • Shared medical staff, board consults at least twice a year, etc.
  • MS by-laws
  • Changes to MS
  • Appraisal of MS
  • Accountability of MS for quality of care
  • Credentialing and privileging
  • CEO requirements
  • History and physicals
  • Autopsy requirements

Quality Assessment and Performance Improvement (QAPI)

  • PI program requirements
  • QAPI worksheet
  • Tracking of medical errors and adverse events
  • Identifying opportunities for improvement
  • Patient safety
  • QAPI new and revised tag numbers in 2020

Radiological Services

  • Radiation exposure
  • Standard of care
  • Adverse reaction to agents
  • Secure area for films
  • Safety precautions
  • Shielding of patients
  • Supervision of staff
  • Radiopharmaceuticals on off hours

Laboratory Services and Look Back Program

  • Lab services
  • Tissues specimens
  • Blood bank
  • Look back program

 Food and Dietary Services

  • Diets and menus
  • Changes RD or nutrition specialist to write diet orders
  • Patient nutritional needs
  • Diet manual and therapeutic menus
  • Qualified director required
  • Dietary policies required
  • Nutritional assessment
  • Therapeutic diets and nutritional needs

Utilization Review

  • Composition of UR committee
  • Admission or continuous stays
  • Medicare patient discharge appeal rights
  • UR plan
  • Scope of reviews
  • Notice Law and MOON form

Physical Environment

  • Buildings and equipment
  • Emergency preparedness (moved to new appendix Z)
  • Compliance with Performance Improvement
  • Life safety code
  • Trash
  • Emergency power and lighting
  • Emergency gas and water
  • Ventilation, light, temperature

Part 5 of 5: Infection Control, Discharge Planning, Organ, Surgery, PACU, Anesthesia, ED, Outpatient, Rehab, and Respiratory


  • Discuss that CMS requires many policies in the area of infection control
  • Recall that patients who are referred to home health, Inpatient rehab, LTCH, and LTC must be given a list in writing of those available and this must be documented in the medical record
  • Describe that all staff must be trained in the hospital’s policy on organ donation
  • Recall that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment
  • Recall that CMS has finalized the discharge planning worksheet and changes to the standards

Infection Control and the final changes

  • Infection preventionist job responsibilities
  • IP appointment
  • IP role in antibiotic stewardship
  • Final infection control worksheet
  • IC revised worksheet and importance
  • Policies and procedures required
  • Mitigation of risks
  • Safe injection practices
  • Immediate use steam sterilization
  • Temperature and humidity issues
  • Medical equipment and supplies
  • Log of incidents
  • Mandatory training

Discharge Planning

  • Final discharge planning worksheet
  • Identification of patient needs,
  • Discharge planning and evaluation
  • Information to be given to the patient
  • Discharge planning responsibility
  • Identification of patients
  • Transfers
  • Referrals
  • Self care
  • Discharge plan and self-care evaluation

Organ, Tissue and Eye Procurement

  • Policy requirements
  • Organ donation training
  • Family notification
  • OPO Notification one call rule

Surgical & Anesthesia Services

  • Follow standards of care
  • Policies required
  • Supervision requirement
  • Preventing OR fires
  • H&P
  • Consent
  • OR register
  • Operative report
  • Required equipment
  • PACU
  • Anesthesia policies required
  • Anesthesia and analgesia standards
  • Pre and post-anesthesia requirements
  • Anesthesia staffing
  • Documentation required
  • Intra-operative anesthesia record

Outpatient Services and final changes

  • No longer accountable to single individual
  • Policies and procedures
  • Meeting needs of patients
  • Outpatient orders
  • Documentation of care given in the OP department
  • Orders required
  • Department director job description and responsibilities

Emergency Services

  • Following standards of practice
  • Integrated into hospital PI
  • Qualified medical director
  • Policies required
  • Training required
  • Length of time to transport between departments

Rehabilitation and Respiratory Services

  • Integrated into QAPI
  • Standards of care
  • Qualified director
  • Plan of care
  • Scope of services
  • Order needed
  • Policies required

CEO, COO, CNO, CMO, Quality Manager, Consumer Advocate, Nurse Educator, Department Directors, All Nurses, Risk Managers, Hospital Legal Counsel, Compliance Officers, Joint Commission Liaison, Director of Health Information, Case Managers, Pharmacists, Pharmacy Director, Social Workers, Discharge Planners, PI Coordinator, Patient Safety Officer, Patient Safety Committee, Outpatient Director, Director of Rehab, Dieticians, Infection Control, Medication Management Team, Anesthesia and Surgery Staff, PACU Director, Policy Procedures Committee, Respiratory Therapy Director, Director of Radiology, Infection Prenvetionist

January 14; 5:00 p.m. MTN

Access instructions and materials will be emailed to the person completing the order prior to the program date. If you do not receive the instructions at least 24-hours in advance, please contact IHA.


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January 21
8:00 am - 10:00 am MST
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