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:

Laura Dixon, J.D., RN, president, Healthcare Risk Education and Consulting
Laura Dixon, J.D., RN, has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020 where she provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. 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.