The CMS Hospital Conditions of Participation (CoPs) 2022
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April 6, 13, 20, 27 and May 4, 2022

Noon-2 p.m. Central


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 apply 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.

Learner Objectives

Part 1

  • 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
  • Describe the changes to medical record requirements, including interoperability and “blocking”

Part 2

  • Recall that CMS has restraint standards that hospitals must follow
  • Describe that a hospital must have a grievance policy and procedure in place
  • Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
  • Describe how non-physician practitioners – PA, NPs – can order restraints

Part 3

  • Describe which medications must be given timely and within one of three blocks of time
  • Recall that all order/protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
  • Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
  • Discuss patient safety issues with compounding pharmacies
  • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Part 4

  • Recall the requirement for and elements of a QAPI program
  • Describe the need for radiology policies, including one on radiation safety and the need for qualified staff
  • Discuss the new option of credentialing the dietician to order diets – if allowed by the state
  • Describe the need for facility maintenance program to include water management

Part 5

  • Discuss that CMS requires many policies in infection prevention and control
  • Recall that patients referred a post-acute care provider – PAC – 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

Target Audience:

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.

Faculty:

Lena Browning, MHA, RNC-NIC, CSHA, Consultant, Nash Healthcare Consulting
Lena Browning is a nurse leader and accreditation specialist with more than twenty-five years of experience in clinical leadership in acute care settings. Throughout her career, she has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence in patient care across healthcare settings.

As a Principal Consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled 3 Interim positions as Director of Accreditation and was responsible for restructuring accreditation departments and leading organizations in continuous compliance and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey. Since then, those three organizations have had successful surveys with no condition-level findings. She is a true pioneer in leadership development and coaching for excellence in healthcare accreditation.

Sharon Courage, MPH, RN, Consultant, Nash Healthcare Consulting
Sharon Courage is a Registered Nurse with a Master’s in Public Health. She has thirty years of experience in hospital quality and risk management, quality improvement, development of hospital programs, patient safety, and acute and long-term care.

From 2002 until the present, Sharon has served hospitals nationwide in developing programs and system improvements in patient safety, quality and risk management, infection control, program assessment, and accreditation preparation. She has assisted with the development and implementation of regulatory plans of correction, process development and implementation as well as process design for automation and electronic medical record documentation simplification.

Sharon has also assisted hospitals with assessment and strategy development and implementation to meet Joint Commission and CMS compliance including the development of sustainable strategies following conditional CMS survey findings.