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Webinar: The CMS Hospital Conditions of Participation (CoPs) Made Easy 2020 Part 5
Wednesday, September 02, 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 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
  • Understand 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 appointed by the board
  • IP role in antibiotic stewardship
  • Final infection control worksheet
  • IC revised worksheet and importance
  • IP responsibilities
  • 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
  • Final changes to discharge planning
  • Identification of patient needs,
  • Discharge planning and evaluation
  • Patient provided written copy of Home health and LTC
  • Discharge planning responsibility
  • Identification of patients
  • Transfers
  • Referrals
  • Self care
  • Timely discharge evaluation
  • Discharge plan and self care evaluation
  • CMS discharge planning worksheet

Organ, Tissue and Eye Procurement

  • Policy requirements
  • Board required
  • Organ donation training
  • Family notification
  • OPO Notification one call rule
  • CMS OPO memo

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

Contact: Tammy Wells