CMS Hospital Improvement Final Rules

CMS Hospital Improvement Final Rules

Dec. 4, 2019
Noon-2 p.m. Central

CMS has finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This include changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. Most have an effective date of November 29, 2019 with two exceptions. The normal implementation date is 60 days, but Critical Access Hospitals will have 6 months to implement an antibiotic stewardship program and 18 months to implement a QAPI program since their QAPI requirements were completely written.  

Learning Objectives:

  • Recall that hospitals have requirements in the CMS CoPs on antimicrobial stewardship program;
  • Discuss CMS changed the term LIP (licensed independent practitioner) to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments if allowed by the hospital;
  • Describe that the hospital must have policies for which outpatient areas require a RN;
  • Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths.

Target Audience:

Pharmacist, chief nursing officer, health information management, infection preventionist, antimicrobial stewardship team members, nurses, nurse educators, chief medical officer, QAPI director and staff, patient safety officers, regulatory and compliance officers, physician assistants (PAs), patient advocate, risk management, nurse educators, hospital legal counsel, MEC chair, board members, and anyone involved in implementing the hospitals CoPs.


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.

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