CMS Hospital Conditions of Participation (5 part series)

April 12, 19, 26, May 3 and 10, 2023



Complete Hospital Manual

About the Series:
Nash Healthcare Consulting’s (NHC) live programs cover the entire CMS Hospital Conditions of Participation manual. All Hospitals that accept payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. The Conditions of Participation 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, HFAP, CIHQ, and DNV Healthcare must follow these regulations.

This program is a great way to educate your hospital employees on all the sections in the CMS hospital manual, especially ones that apply to their respective departments.  Speakers will discuss the most problematic standards as well as how the hospital can do a gap analysis to assist in compliance with the Conditions of Participation. This is a must attend for experienced employees that need a refresher, or newer employees to become familiar with compliance standards.

Who Should Attend:
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.

CMS CoPs – Part 1

Wednesday, April 12, 2023, Noon-2 p.m.

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.
  • Discuss that verbal orders must be signed off by the physician along with a date and time.

CMS CoPs – Part 2

Wednesday, April 19, 2023, Noon-2 p.m.

Learning Objectives:

  • 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.
  • Discuss that the term LIP (licensed independent practitioner) has been changed to LP (licensed practitioner) to allow PAs to order restraints.

CMS CoPs – Part 3

Wednesday, April 26, 2023, Noon-2 p.m.

Learning Objectives:

  • Describe how 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.
  • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy.

CMS CoPs – Part 4

Wednesday, May 3, 2023, Noon-2 p.m.

Learning Objectives:

  • 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.
  • Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state.

CMS CoPs – Part 5

Wednesday, May 10, 2023, Noon-2 p.m.

Learning Objectives:

  • 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.
  • Understand that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment.
  • Recall that CMS has finalized the discharge planning worksheet and changes to the standards.

About the Speaker(s)

Speaker: Nash Healthcare Consulting