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

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.

Critical Access Hospital (CAH) Conditions of Participation 2021: Ensuring Compliance

Multi-part webinar series that covers the entire manual – Part 1 – Jan. 19; Part 2 – Jan. 26; Part 3 – Feb. 2; Part 4 – Feb. 9; Part 5 – Feb. 16

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.

Due to COVID-19, the registration fee is per hospital and not per connection for this webinar series. A single registration provides multiple lines for employees at 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. 


Part 1-4 | There were over 300 pages of regulations for CAHs in 2020.  Many of the most recent new Tag numbers do not include Interpretive Guidelines or Survey Procedures. There are several important memos about COVID-19 that will be discussed.

This four-part webinar will cover the entire CAH CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that apply to their department.  Common deficiencies and how to avoid them will be discussed. Hospitals will learn how to do a gap analysis to increase compliance.

There were many changes in 2020 to discharge planning, antibiotic stewardship program, access to medical records, QAPI, infection control, policy review time frames, emergency preparedness, credentialing of the dietician, quality and appropriateness of the diagnosis, changes to the swing bed requirements, life safety code and facility services, infection control plus the revised emergency preparedness requirements.

CMS made updates for COVID-19 reporting that impact hospitals, laboratories, and any nursing home.  Those changes and new requirements impact the duties and responsibilities of hospitals who own or operate a laboratory on site or an affiliated nursing home.

CMS has issued many important hospital memos including privacy and confidentiality, texting of orders, humidity in the OR and the effects of humidity, insulin pens, safe injection practices, reporting to the QAPI program, complaint manual update, contracts, telemedicine and EMTALA, equipment and maintenance, disaster preparedness, and ligature risks.

While CMS is not using the infection control worksheet at CAHs at this time, the webinar will discuss why using the worksheet as a self-assessment tool. There is also a final and revised worksheet on discharge planning and QAPI.

Other areas to be covered include: nursing care plans, necessary policies and procedures, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness.

Part 5 | This program is a must attend for critical access hospitals as Critical Access Hospitals have until March 2021 to comply with the QAPI standards.  Additionally, QAPI is one of only three CMS survey sections with a worksheet. The program will discuss the revised CMS hospital QAPI standard and the final changes to QAPI that were effective November 29, 2019.  CMS implemented a similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule and Interpretive Guidelines are still pending. Nonetheless, Critical access hospitals (CAHs) had an additional 18 months to implement the new standards – or until March 2021.  

The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI.  The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys.

Every hospital that accepts Medicare and Medicaid must be in compliance. The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are from CMS. QAPI is an important issue to CMS and an increased area of focus.

This program will discuss the memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, it is estimated that 86% of adverse event are never reported to the hospital’s PI program. Performance improvement is very important to CMS and the hospital conditions of participation require many things to be measured.

PART 1 of 4 Introduction, Memos, Compliance, Agreements, Contracts, Board Duties, Emergency Services, Observation and Physical Environment 

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

  • Describe the method find information on CMS regulations
  • Recall the process to identify common deficiencies cited by CMS
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs
  • Identify changes to CMS CoP manual within the last 3 years 


  • History
  • How to find CMS manuals, survey memos and changes
  • CAH problematic standards
  • CMS websites and CAH Resources
  • Conditions of participation

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

Overview of CAH

  • Basis and scope
  • Rural Health Network
  • Personnel Qualifications
  • Designation and Certification of CAHs 

Agreements and Organization Structure and Board Duties

  • Personnel Qualifications
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Status and Location
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Governing Body
  • Staffing and Responsibilities
  • Physician responsibilities
  • Transfer of patient
  • Patient admissions
  • Medical management
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality
  • Agreements for Telemedicine

Emergency Services and Observation

  • Emergency Services
  • ED staffing
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Number of Beds and Length of Stay
  • Observation, two midnight rule
  • Number of Beds
  • Length of Stay

Physical Environment

  • Physical Plant and Environment
  • Maintenance and equipment
  • Disposal of trash
  • Storage of drugs and biologicals
  • Physical environment and ventilation
  • Construction and equipment
  • Life Safety from Fire
  • LSC waivers
  • Fire inspections
  • Emergency Preparedness – also in Appendix Z

Part 2 of 4 Provision of Services: Nursing, Pharmacy, Dietary, Drugs and Equipment, Surgery, Anesthesia and ED

Objectives – At the conclusion of part two, participants should be able to:

  • Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
  • Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use.
  • Recall the requirements for security and storage of medications, medication carts and anesthesia carts,
  • Recall the requirements for nursing services and order sets, and protocols.
  • Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs.

Provision of Services

  • Patient care policies
  • Review of and required policies
  • Direct Services
  • Services Provided through Agreements or Arrangements
  • Drug and biologicals
    • Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, definition of medication error, adverse event, indicator or trigger drugs 


  • Nursing care
  • Observation of med passes/nursing care
  • Nursing care plans
  • RN – required and supervision
  • Drugs and IVs
  • Medication administration
  • Timing of medications
  • Safe opioid use
  • IVs and Blood
  • Verbal and Standing orders
  • Self-medication administration 


  • Inspections/staff interviews
  • Dispensing of drugs
  • Pharmacist responsibilities
  • Staffing
  • Pharmacy policies and procedures
  • Medication therapy monitoring
  • Emergency medicine kits
  • Drug storage and maintenance
  • Nursing med carts/anesthesia carts
  • Survey of pharmacy
  • Reporting ADR and medication errors
  • High alert medication
  • Definition of medication error required
  • Trigger/indicator drugs
  • Medication alerts
  • Do not use abbreviations
  • Sound alike/look alike drugs

Dietary and Nutrition Services

  • Dietary policies
  • Credentialing and Privileging of Dietician
  • Meeting patient needs, diet order, follow recognized dietary practices
  • Dietary support staff
  • Assessment of patients and order

Surgical Services

  • Surgery policies required
  • Informed consent
  • PACU
  • OR register
  • Operative report
  • Surveyor in the OR
  • Surgical privileges
  • Designation of Qualified Practitioners

Anesthesia services

  • Anesthetic Risk and Evaluation
  • Administration of Anesthesia
  • Pre-anesthesia evaluation
  • Post-anesthesia evaluation
  • Discharge
  • PI required
  • Healthcare-associated infections
  • State Exemption of CRNAs
  • Periodic Evaluation

Part 3 of 4 Infection Control, Safe Medication, Lab, Patient Services, Outpatient, and Discharge Planning


  • Recall that the infection preventionist must be appointed by the board
  • Recall that CMS has an infection control worksheet that may be helpful to CAHs
  • Discuss proper insulin pens usage
  • Describe that an order is needed to allow the patient to self-administer medications
  • Explain that there are three-time frames in which to administer medications
  • Discuss what CMS requires for discharge planning

Infection Prevention and Control and Antibiotic Stewardship Program

  • Final changes to infection control
    • Antibiotic stewardship requirements
  • Infection control worksheet
  • CDC and FDA health update
  • Investigating and controlling infections
  • Healthcare associated infections
  • Four challenges in infection control
  • Infection control orientation new employees
  • Surveillance, sanitary environment, and mitigation of risks
  • Role of leaders in infection control
  • Infection control officer

Safe Medication Practices

  • Preparation and administration
  • CMS IC worksheet and safe injections
  • Single and multi-dose vials
  • Fingerstick devices, scopes, glucometers, insulin pens


  • Services and staffing
  • COVID-19 reporting requirements

Patient Services

  • Diagnostic and therapeutic services
  • Supplies 

Outpatient Services

  • Outpatient department
  • Outpatient director
  • Final changes
  • Board and MS action 

Discharge Planning

  • Planning process
  • Patient involvement
  • Patient rights 

Part 4 of 4 Radiology, Organ Procurement, Rehab, Visitation, Medical Records, QAPI, and Swing Beds

Objectives – At the conclusion of part three, participants should be able to:

  • Explain the informed consent elements required by CMS,
  • Describe the requirements for history and physicals for CAH,
  • List what must be contained in the operative report,
  • Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency when a patient expires,
  • Recall that CMS has many patient rights that are afforded to patients in swing beds.
  • Recall that hospitals must have a visitation policy and patients must be informed 


  • Radiology services
  • Radiology staff
  • Scope of radiology services
  • Radiology policies required

Organ, Tissue and Eye Procurement

  • Definition of imminent death
  • Tissue and eye bank
  • Family notification
  • Organ donation

Rehab section

  • Order required
  • Plan of care requirements


  • Written copy of rights to patient and document
  • Patient advocate
  • When patient is incapacitated/incompetent
  • P&P required
  • Staff education required

Medical Records

  • Final changes
  • Timely access to medical records
  • HHA HIPPA changes – access
  • OCR fines
  • Medical record standards
  • Identification of author
  • Inpatient and outpatient requirements for medical records
  • Records System
  • Informed consent
  • History and physicals
  • Reports of examinations, diagnostic test results and consults
  • Discharge summaries
  • Preventing unnecessary readmissions
  • Documentation to monitor patient’s progress
  • Confidentiality of medical records
  • Retention of medical records 


  • Required process
  • Necessary members

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)

  • Eligibility
  • Payment
  • SNF Services
  • Resident Rights
  • Notice of Rights and Services
  • Privacy and Confidentiality
  • Mail
  • Access and Visitation Rights
  • Personal Property
  • Admission, Transfer and Discharge Rights
  • Resident Behavior and Facility Practices
  • Restraints, Abuse
  • Hiring of employees
  • Activities
  • Social Services
  • Dental requirements
  • Resident Assessment
  • Comprehensive Care Plans
  • Discharge Summary
  • Nutrition
  • Provision of Services

PART 5 CMS Hospital QAPI Worksheet for Critical Access Hospitals

CMS Final QAPI Worksheet

  • Number of deficiencies hospitals received
  • Final worksheet
  • 2020 changes
  • Indicators selected
  • Scope of data collection
  • Collection methodology
  • Number of projects
  • Focus – severity, high volume, etc.
  • RCA and causal analysis tracers
  • TJC Sentinel Events and framework for doing RCA
  • Interventions etc.
  • PI requirements and leadership
  • Board responsibility for PI

 CMS CoP Manual Standards on QAPI

  • Revised QAPI requirements November 29, 2019
  • CAH final QAPI under the Hospital Improvement Rule
  • CAH ten new tag numbers for QAPI in 2021
  • CMS memo on reporting into the QAPI system
  • Number of deficiencies in the QAPI standards
  • Ongoing PI program
  • No hospital wide QAPI program for CAH
  • Prevention and reduction of medical errors
  • Program scope
  • Measureable improvements
  • Analyze and tracking of performance indicators
  • Program data
  • Tracking adverse events
  • Ensuring compliance with program data requirements
  • Identifying opportunities for improvement
  • Board responsibilities for PI
  • QIO projects and changes in QIO functions
  • PI priorities
  • Issues to improve patient safety, reduce medical errors and ADEs
  • Three RCAs or root cause analysis
  • Number of PI projects
  • Documentation requirements
  • Executive responsibilities
  • Providing adequate resources
  • Resources: TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.


  1. Recall that CMS has a worksheet on QAPI
  2. Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  3. Discuss the rewritten the QAPI requirements CMS implemented for CAHs
  4. Discuss the Governing Board’s ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
  5. Recall that hospitals are receiving a high number of deficiencies in QAPI

CEO, COO, CFO, CNO, accreditation and regulation director, nurse managers, pharmacist, quality manager, risk manager, healthcare attorney, health information management personnel, social workers, dieticians, nurses, nurse educators, nursing supervisors, patient safety officer, infection preventionist, radiology director and staff, laboratory director, emergency department director, outpatient director, medication team, ethicist, director of Rehab (OT, PT, speech pathology, and audiology), OR supervisor, OR staff, CRNA,  anesthesia providers, activities director of swing bed patients, infection control committee members, compliance officer, performance improvement director and staff, and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met.

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.  Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa.  She is licensed to practice law in Colorado and California.

January 12; 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.

2020 ID Chapter of ACHE Virtual Face-to-Face Education Event

Ensuring Your Community’s Emergency Preparedness
Presented by

In the best of circumstances, healthcare organizations operate in a complex environment. This can be exacerbated when a community faces a local or national emergency, either natural, human-caused, or technological, that thrusts the healthcare system to the forefront of response and makes it the focus of recovery efforts. It is critical that the local healthcare community be actively engaged in the development of comprehensive emergency preparedness plans, training, and exercises to ensure that local organizations communicate and coordinate their mutual support in service to the community.

Learning Objectives

  • Review the most common local and national hazards
  • Discuss the strengths and weaknesses of local and national response plans
  • Describe the relationship between local healthcare organizational plans and action to local governance
  • Potential outcomes to current organizational plans
  • How to plan for the “unexpected”
  • Detail potential risks to planning without alignment to local or national plans or standards
  • Key take-aways for the audience to replicate at their organizations
  • Moderator: Lisa Bisterfeldt, Program Manager, IHT Cyber Security, St. Luke’s Health System
  • Panelist: David Hoffenberg, Chief Operating Officer, Eastern Idaho Regional Medical Center
  • Panelist: Kathryn “Katy” Quinn, Safety Officer, Saint Alphonsus Health System

This program has been developed and is presented locally by the Idaho Healthcare Executive Forum. The American College of Healthcare Executives has awarded 1.5 ACHE Face-to-Face Education Credits for this program.

Registrants will receive an email invite from Roger Winslow which will include connection information, as well as an evaluation form to be completed and returned.

Please direct questions on this event to:

Roger Winslow

The Joint Commission Life Safety Standards

Based on the 2012 Education of the Life Safety Code

The registration fee is per person for this webinar. 

This webinar will focus on the recent changes, areas of focus, and trouble spots regarding the Joint Commission Life Safety Standards that are based on the NFPA 101 Life Safety Code – 2012 Edition. The presentation is also applicable to hospitals that are accredited by DNV Healthcare that also enforces the Life Safety Code – 2012 Edition. This program will review requirements regarding Interim Life Safety Measures, Life Safety Drawings, and areas of focus regarding the Life Safety Code Healthcare Occupancy requirements.

Upon completion of this program, participants will be able to:

  • Understand current requirements regarding Statement of Conditions and Life Safety Code assessment;
  • Understand when interim life safety measures are required;
  • Understand requirements for life safety drawings;
  • Understand requirements for sleeping and non-sleeping patient care suites; and
  • Understand when a risk assessment of an operating room as a wet procedure location is required.

CEOs, CNOs, risk managers, hospital plant managers/engineers, facility managers, directors of buildings and grounds, compliance officers, safety officers and hospital personnel who are responsible for The Joint Commission Accreditation Life Safety Code compliance

Fred J. Osborne, P.E., is president of Osborne Engineering, Inc., located in Wilmette, Illinois. He has more than 34 years of national healthcare consulting experience and has been a clinical faculty member with The Joint Commission.  Additionally, he has been a member/advisor of the Joint Commission Committee on Healthcare Safety and has extensive experience with both teaching The Joint Commission Environment of Care and Life Safety Standards, as well as working directly with healthcare organizations.

November 26; 5:00 p.m. MST

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.

Overhaul of E/M Codes Updates for 2021 – 3-Part Webinar Series

Part 1 – December 1, 2020; Part 2 – December 15, 2020; Part 3 – January 12, 2021; 8:00 a.m. – 10:00 a.m. MT

Due to COVID-19, the registration is per hospital and not per connection for this webinar series. Each hospital in a system much register separately for this series.  Please only select a qty. of “1” under Registration and indicate the number of connections requested when completing the Attendee information.

This program is intended to provide participants with an overview of the CPT® Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guidelines being overhauled for the first time in more than 25 years. E/M documentation guidelines for new and established office and outpatient services (99202 – 99215) have gone through substantial revisions that become effective Jan. 1, 2021. This change is significant due to the large number of office visits that are performed each year by every specialty. This three-part webinar series will cover new guidelines, including eliminating history and physical exam as elements for code selection and allowing physicians to choose the code level based on medical decision-making or total time to name a few.

“To get the full benefit of the burden relief from the E/M office visit changes, healthcare organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” said AMA President Susan R. Bailey, M.D. “

Topics to be covered:
• What you need to do to get your providers ready;
• What we know and not know yet;
• What to look for to develop training curriculum for your providers;
• What it means for compliance auditing; and
• Resources you currently need and should watch out for.

  • Identify changes that will occur with the 2021 CPT updates; and
  • Review resources for questions and updates as changes occur.

HIM coders, CDI staff, case managers, documentation improvement staff, risk coders, physician office, and MDS coordinators and auditors

Jean Ann Hartzell-Minzey, RHIA, CHA, CPC, CEO & Chair of the Board Healthcare Education Strategies, Inc. (HES)

HES is a national consulting firm headquartered in Louisiana. Jean Ann Hartzell-Minzey actively develops systems and innovative programs for healthcare leaders and trainers. Her approach towards ICD-10-CM and ICD-10-PCS reflects her clinical knowledge and her knowledge of reimbursement methodologies. She implemented one of the first DRG systems in the country, and as part of the implementation, she educated 280 members of the medical staff one-on-one. She is certified by the American Health Information Management Association. She looks at ICD-10 training in a purposeful, practical way with the goal of providing functional education to the point where there is measurable improvement. As a certified healthcare auditor, she is proficient in the critical areas of audit compliance and national standards for auditing as established by the American Society for Quality, consistent with methodologies used by the Centers for Medicare & Medicaid Services and the Office of Inspector General.

Tuesday, November 24; 5:00 p.m. MT

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.

Not sure if you can make the live program date(s)? All registrants will receive the recording link approximately two days after the session date. The link will be active for two months post-session.