CMS Hospital Conditions of Participation Made Easy 2020

July 29, Aug. 5, 12, 19 & 26

Noon-2 p.m. Central

Reduced pricing! Member rate, $65 per webinar. Non-member rate, $115 per webinar.

Sue Dill Calloway, RN, J.D., will review the CMS 1135 waivers that are in place during the COVID-19 pandemic and the 700 pages of changes to the CMS CoP manual. The speaker also will review the updated discharge planning and infection control standards for all hospitals, including a review of the targeted infection control surveys related to COVID-19.

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.

This program will also 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.

Learning Objectives:

  • 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; and
  • Discuss that verbal orders must be signed off by the physician along with a date and TIME.
  • 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; and
  • Discuss that the term LIP (licensed independent practitioner) has been changed to LP (licensed practitioner) to allow PAs to order restraints.
  • Describe that medications must be given timely and within one of three blocks of time;
  • Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off;
  • Recall that there are many pharmacy policies required by CMS;
  • Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record; and
  • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy.
  • Recall that CMS has patient safety requirements in the QAPI section that are problematic standards;
  • Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified; and
  • Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state.
  • 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;
  • Explain the specific items that CMS requires be documented in the medical record regarding the post-anesthesia assessment; and
  • Recall that CMS has finalized the discharge planning worksheet and changes to the standards.

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.


Sue Dill Calloway, RN, J.D., president, Patient Safety and Healthcare Education and Consulting
Sue Dill Calloway, RN, J.D., has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and also the chief learning officer for the Emergency Medicine Patient Safety Foundation. Prior to her current role, she was the director of hospital patient safety for The Doctors' Company and OHIC Insurance Company. She has led many educational programs for nurses, physicians, and other health care providers. Dill has authored more than 100 books and numerous articles. A frequent speaker, Dill is well known across the country in the area of health care law, risk management, and patient safety.