The CMS Hospital Conditions of Participation (CoPs) 2021

April 7, 14, 21, 28 and May 5

Noon-2 p.m. Central

Laura Dixon, J.D., RN 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 include the 600 pages of final changes in 2020 and where the gaps continue, for example, in the absence of interpretive guidelines and survey procedures. This includes 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. This program will also include information as to the new reporting requirements for COVID-19 and implications for non-compliance.

Learning Objectives:

Part 1 of 5: Introduction, CMS Survey Memos, Surveyor Training Material, Hospital deficiency reports, CMS 3 worksheets, CDC Vaccine, OCR 1557, Required Education, Hard Hit Areas, Board and Medical Staff, Budget, Contracts, Emergency Services, Medical Records, Standing Orders, H&Ps, COVID-19 reporting requirements

  • 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; and
  • Explain the implications for non-compliance with COVID-19 reporting

Part 2 of 5: Patient Rights: Advance Directives, Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, Restraints and Visitation

  • 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.

Part 3 of 5: Nursing and Pharmacy

  • 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.

Part 4 of 5: QAPI, Medical Staff, Dietary, Radiology, Lab, UR, and Facility Services

  • 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; and
  • Review related COVID-19 reporting requirements

Part 5 of 5: Infection Control, Discharge Planning, Organ, Surgery, PACU, Anesthesia, ED, Outpatient, Rehab, and Respiratory

  • 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.


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.