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Webinar: The CMS Hospital Conditions of Participation (CoPs) Made Easy 2020 Part 2
Wednesday, August 12, 2020, 10:00 AM - 12:00 PM EDT
Category: Education

If a CMS surveyor showed up in your hospital tomorrow, would you be prepared? This five part webinar series will cover the entire CMS Hospital 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 applies to their department.  Hospitals have seen a significant increase in survey activity by CMS. This program will discuss the most problematic standards. The program will cover how the hospital can do a gap analysis to assist in compliance with the CoPs.


This program will also include the 600 pages of final changes in 2020. This includes the final discharge planning standards and the Hospital Improvement Rule. This includes changes to history and physicals, system wide QAPI and infection control, autopsy, discharge planning, infection control, antibiotic stewardship, medical records, nursing, outpatient, the role of non-physicians in psychiatric hospitals and more. The ligature risk and prevention of suicide will be covered which is a hot area of compliance.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. This 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 must follow these regulations.

There are sections on medical record services, dietary, utilization review, emergency department, surgical services, anesthesia, PACU, medical staff, nursing services, lab, outpatient department, rehabilitation, radiology, respiratory, physical environment, pharmacy, infection control, organ and tissue, patient rights and discharge planning. Hospitals should perform a gap analysis to ensure they are compliant with all these interpretive guidelines and assign one person to be responsible for ensuring compliance.

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 proposed changes to the infection control worksheet will be discussed. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance.

Changes in the recent past were made to the medical staff, board, radiology, nuclear medicine, UR, nursing, pharmacy, dietary and outpatient regulations. There were changes to texting of orders, ligature risks, discharge planning, safe opioid use, IV medication, blood and blood products, safe opioid use, privacy and confidentiality, visitation, informed consent, advance directives, rehab and respiratory orders, radiology, QAPI, texting of orders, preventive maintenance, timing of medication, telemedicine, standing orders, informed consent, plan of care, humidity level, Complaint manual and reporting the accreditation organizations, organ procurement contracts, and adverse event reporting to the QAPI program. There were also a record breaking number of survey and certification memos issued over the past few years.

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 that the term LIP (licensed independent practitioner) has been changed to LP (licensed practitioner) to allow PAs to order restraints

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
    • Confidentiality
    • Designation of a representative
    • Right to an IM Notice for Medicare patients
    • Understanding what is a patient advocate/support person
    • Interpreters
    • Low health literacy
    • Advance directives
    • Informed consent
    • Abuse and neglect
    • Criminal background checks
    • Grievances and complaints (TJC)
    • Visitation requirement
    • Patient representative
    • IM Notice for Medicare patients
    • Family member and doctor notification
    • Plan of care
    • Informed consent
    • Advance directives
    • Privacy and confidential
    • Care in a safe setting
    • Privacy and confidentiality memo
    • Patient medical records
    • Access to medical records
    • Restraint and seclusion-high number of deficiencies for hospitals
      • Restraint changes, soft limb restraints and death, internal log verse external log and reporting to CMS, definition, restraint worksheet, right to free from unnecessary R&S, hospital leadership role, definition, medication used as a restraint, R&S do not include, weapons, assessment, less restrictive, alternatives, LP can order, PAs can order, documentation, education requirements, prn orders, plan of care, end at earliest time, PI, one hour rule, renewing restraint orders, and R&S policy.
    • Visitation

Contact: Tammy Wells