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Webinar: The CMS Hospital Conditions of Participation (CoPs) Made Easy 2020 Part 5
Thursday, October 01, 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 One of Five: 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
  • Location of the manual
  • Final changes including discharge planning and the Hospital Improvement Rule
  • Recent revisions
  • Hospital revised worksheets; infection control, PI, and discharge planning
  • Changes in recent past
    • Medication and safe opioid use, medical staff, board, radiopharmaceuticals, dieticians ordering diet, ordering outpatient services, separate MS or unified integrated MS, etc.
  • Changes and memos
    • Ligature risks, texting of orders, Privacy, Legionella, confidentiality, rehab, timing medications, medication errors, humidity, reporting to internal PI, Ebola, worksheets, luer misconnection, safe opioid use, safe injection practices, infection control breeches, organ procurement contracts, deficiency memos, etc.
  • CMS required education
  • What’s really important
  • Survey protocols
  • Survey team
  • Compliance with law
  • Order sets, protocols, standing orders

Board and CEO

  • Board requirements
  • CMS by-laws
  • Appointment to the MS
  • Credentialing and privileges
  • TJC tracer on C&P
  • 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)

  • Final changes
  • 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

Questions on Part 1 from attendees

  1. Can an RN that is privileged and credentialed do the discharge summary for the physician and the MD sign off?
  2. Is a documented P & P required to show how you handle standing orders or is it ok to just be able to speak to the process?
  3. If a hospital protocol has been passed through MEC and Governing Board (such as dietary protocol per dietician) does the physician have to sign the protocol each time as an order? Or can the dietician just write and sign per hospital protocol?
  4. If our own dietician and pharmacist writes orders per protocol passed through MEC, do they have to go through hospital credentialing since they are our own employees.
  5. Can you explain the new changes for doing a pre-procedure assessment instead of an H&P on a healthy outpatient?

Contact: Tammy Wells