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Emergency and Outpatient Services CoPs

June 30, 2020 @ 8:00 am - 10:00 am MDT


Due to COVID-19, the registration is per hospital and not per connection for this webinar. Please only select a qty. of “1” under Registration and indicate the number of connections requested (not to exceed 5) when completing the Attendee information.

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 that you will have 120 days to view at your convenience at no additional charge.

This webinar covers the CMS hospital Conditions of Participation that affect the emergency and outpatient services departments. Any hospital that accepts Medicare must follow the CMS CoPs for all patients.

The webinar will review staffing requirements, provision of services both on and off-campus, EMTALA, required policies and procedures, training requirements, medical director requirement, and compliance standards of care. It will also discuss the requirements for restraint and seclusion, grievances and protocols.

This program will also cover the final changes to the outpatient section, published in the Hospital Improvement Rule that went into effective November 29, 2019. The hospital will be required to have a policy and designate which outpatient departments will require a RN, and additional changes that will be discussed.

  • Manual overview
  • Survey memos
  • EMTALA and 2019 changes
  • Required policies
  • Hospitals without emergency departments
  • Staff training
  • Transport policies
  • On-campus and off-campus responsibilities
  • Medical Staff and emergency procedures
  • Meeting needs of patients
  • Following standards of care (ACEP and ENA)
  • QAPI
  • Lab, x-ray, medical records, surgery responsibilities
  • Equipment and supplies
  • Staffing
  • Grievances
  • Protocol and written policy requirements
  • Final changs effective date of November 29, 2019, including restraint and seclusion
  • Following the acceptable standard of practice
  • Orders 

By the end of this presentation, learners will be able to:

  • Recall that CMS has a section in the hospital CoP manual on emergency services
  • Discuss that CMS requires the emergency department to have specified policies and procedures
  • Describe that there are restraint and seclusion standards that staff must follow
  • Explain what is required if the patient files a grievance
  • Recall that CMS has a section in the hospital CoP manual on outpatient services
  • Discuss that the outpatient department must follow standards of practices
  • Describe that an order is needed for any outpatient test or procedure
  • Recall that hospitals must have a policy and list of all outpatient departments and which ones must be staffed with an RN

Emergency department physicians, nurses, mid-level providers (such as PA and NP) and staff, chief medical officer, chief nursing officer, compliance officer, patient safety officer, in-house legal counsel, risk managers, director of regulatory compliance, nurse supervisors, and anyone who is responsible to ensure compliance with the hospital conditions of participation.

Sue Dill Calloway is president of Patient Safety and Healthcare Consulting and Education company with focus on medical legal education, especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the VP of Legal Services at a community hospital in addition to being the Privacy Officer and Compliance Officer. She was a medical malpractice defense attorney for ten years, and has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

The speaker has no real or perceived conflicts of interest that relate to this presentation.

Tuesday, June 23; 5:00 p.m. MDT

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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June 30, 2020
8:00 am - 10:00 am MDT
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