The CMS Hospital Conditions of Participation Made Easy

If a CMS surveyor showed up in your hospital tomorrow, would you be prepared? This two-day program 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 applies to their department.  Hospitals have seen a significant increase in survey activity by CMS. 

This program will also include the proposed changes in 2018 on discharge planning and the IMPACT Act. The hospital will need to get the discharge summary in the hands of the primary care physician within 48 hours. There are five new quality measures, five new things to add to the assessment form, medication reconciliation, providing written information on side effects of medication, five things that will have to be in the discharge instructions and more. 

The 2018 proposed changes in the Hospital Improvement Rule will be discussed. This makes many changes including a requirement for an antibiotic stewardship program and changes to nursing, medical records, QAPI, and more.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. This 525 page 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 (TJC), HFAP, CIHQ, and DNV Healthcare must follow these regulations.

The November 20, 2015 manual implemented ten tag number changes in pharmacy and tag 405 in nursing. The July 10, 2015 manual rewrote all of the radiology and nuclear medicine sections. The October 9, 2015 included the definition of spouse for individuals of same sex marriages. 

The interpretive guidelines serve as the basis for determining hospital compliance and there have been many changes in the recent years. There have been significant changes and many important survey memos issued also. CMS issued the final surveyor worksheets for assessing compliance with the QAPI, infection control and discharge planning standards. The proposed changes to the infection control worksheet will be discussed. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance. 

Changes in the recent past were made to the medical staff, board, radiology, nuclear medicine, UR, nursing, pharmacy, dietary and outpatient regulations. There were changes to discharge planning, safe opioid use, IV medication, blood and blood products, safe opioid use, privacy and confidentiality, visitation, informed consent, advance directives, rehab and respiratory orders, radiology, QAPI, preventive maintenance, timing of medication, telemedicine, standing orders, informed consent, plan of care, humidity level, Complaint manual and reporting the accreditation organizations, organ procurement contracts, and adverse event reporting to the QAPI program. There were also a record breaking number of survey and certification memos issued over the past few years.

There also are sections on medical record services, dietary, utilization review, emergency department, surgical services, anesthesia, PACU, medical staff, nursing services, outpatient department, rehabilitation, radiology, respiratory, physical environment, infection control, organ and tissue, patient rights and discharge planning. Hospitals should perform a gap analysis to ensure they are compliant with all these interpretive guidelines and assign one person to be responsible for ensuring compliance.
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
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
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
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
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 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

The agenda will cover: 

Overview of the CMS Survey Process and Introduction
Location of the manual
Proposed changes in 2018
Revisions in 2015 and 2016 
Hospital revised  worksheets; infection control, PI, and discharge planning
Changes in recent past
Medication and safe opioid use, medical staff, board, radiopharmaceuticals, dieticians ordering diet, ordering outpatient services, separate MS or unified integrated MS, etc.
Changes and memos
Privacy, Legionella, confidentiality, rehab, timing medications, medication errors, humidity, reporting to internal PI, Ebola, worksheets, luer misconnection, safe opioid use, safe injection practices, infection control breeches, organ procurement contracts, deficiency memos, etc.
CMS required education
What’s really important
Survey protocols
Survey team
Compliance with law
Order sets, protocols, standing orders

Board and CEO
Board requirements
38 pages of changes Sept 2014
MS by-laws
Appointment to the MS
Credentialing and privileges
TJC tracer on C&P
Medical staff and the board
Single medical staff or unified integrated MS
Privileging others such as PharmD, podiatrist, RD, etc.
CEO requirements
Care of patients
Plan and budget
Contracted services
Emergency services

Medical Records (Health Information Management)
Proposed changes in 2018
Final drug and alcohol federal law (substance use disorder records)
Organization and staffing
Confidentiality of records
Content of records
Legibility requirements
Informed consent mandatory and optional elements
Verbal orders
Signature stamps and guidelines
Discharge summary

Patient Rights 
Proposed changes in 2018
Right to privacy and safety
Designation of a representative
Right to an IM Notice for Medicare patients
Understanding what is a patient advocate/support person
Low health literacy
Advance directives
Informed consent
Abuse and neglect
Criminal background checks
Grievances and complaints (TJC)
Visitation requirement
Patient representative
IM Notice for Medicare patients
Family member and doctor notification
Plan of care
Informed consent
Advance directives
Privacy and confidential 
Care in a safe setting
Privacy and confidentiality memo
Patient medical records
Access to medical records
Restraint and seclusion-high number of deficiencies for hospitals
Restraint changes, soft limb restraints and death, internal log verse external log and reporting to CMS, definition, restraint worksheet, right to free from unnecessary R&S, hospital leadership role, definition, medication used as a restraint, R&S do not include, weapons, assessment, less restrictive, alternatives, LIP can order, documentation, education requirements, prn orders, plan of care, end at earliest time, PI, one hour rule, renewing restraint orders, and R&S policy.

 Nursing Services 
Proposed 2018 changes
Director of nursing (CNO)
Medication administration and safe opioid use
Safe injection practices and compounding
Policies and procedures
Nursing care plan
Staff competency
Preparation and administration of drugs 
Licensure verification
Nursing linked to safety
Self administration of medication 
IV and blood transfusions 
Reporting medication errors and ADEs
Agency nurses
30 minute medication rule changes
Timing of medication 3 
Orders, protocols, standing orders, order sets
Verbal orders
IV medication and blood transfusions
Incident reports

Pharmaceutical Services 
Proposed antibiotic stewardship program in 2018
Major revision in 2016; BUD, compounding and more
November 20, 2015 manual red line pharmacy changes
o 10 tag numbers revised and new one (490)
Administration of medication within 1 hour from preparation of CSP
Compounding and amended nursing tag 405
o Use of compounding pharmacies
o Obtaining from compounding pharmacy v. manufacturer or registered outsourcing facility
o BUD, packaging, and labeling of medications
Must follow professional standards of care such as USP
Best practices recommendations such as ISMP and ASHP
Preparing CSPs outside the pharmacy
Storage of drugs
Radiopharmaceuticals on off hours
Pharmacy administration and must meet needs of patients
P&P to minimize drug error
Standardization of prescribing and communication practices
Floor stock
Patient safety
Drugs and biological
First dose review
High-risk medication
Definitions of medication errors, ADE and DI
Notification of physician
Policies required and training on policies
Pharmacy requirements
Storage and security of medications
Self administration of medication
Outdated or mislabeled medications or unusable drugs
Drug interactions and side effects
Night pharmacy cabinet standards
PI requirements for adverse drug events

Medical Staff, Board, and CEO
Shared medical staff, board consults at least twice a year, etc.
MS by-laws
Changes to MS
Appraisal of MS
Accountability of MS for quality of care
Credentialing and privileging
CEO requirements
History and physicals
Autopsy requirements

Quality Assessment and Performance Improvement 
PI program requirements
Proposed 2018 changes
QAPI worksheet
Revised tag numbers 
Tracking of medical errors and adverse events
Identifying opportunities for improvement
Patient safety

Radiological Services 
Rewritten July 10, 2015
Radiation exposure
Adverse reaction to agents
Secure area for films 
Safety precautions
Shielding of patients
Order required
Supervision of staff
Signing of radiology reports
changes radiopharmaceuticals on off hours

Laboratory Services and Look Back Program
Lab services
Tissues specimens
Blood bank
Look back program
Fully funded plan

 Food and Dietary Services 
Diets and menus
Changes RD or nutrition specialist to write diet orders
Patient  nutritional needs 
Diet manual and therapeutic menus
Qualified director required
Dietary policies required
Nutritional assessment
Infection control is important!
Order required
Therapeutic diets and nutritional needs

 Utilization Review 
Composition of UR committee
Admission or continuous stays 
Medicare patient discharge appeal rights 
UR plan
Scope of reviews
Notice Law and MOON form

Physical Environment
Buildings and equipment
2017 changes emergency preparedness moved to new appendix Z
Compliance with PI
Life safety code
Emergency preparedness
Emergency power and lighting
Emergency gas and water
Ventilation, light, temperature

Infection Control and 2018 proposed changes
Infection preventionist
Final infection control worksheet
IC revised worksheet and importance
IP responsibilities
Policies and procedures required
Mitigation of risks
Safe injection practices
Immediate use
Medical equipment and supplies
Log of incidents
Mandatory training

 Discharge Planning 
Proposed changes in 2017/2018 and IMPACT law
Final discharge planning worksheet
Identification of patient needs,
Discharge planning and evaluation 
Patient provided written copy of  Home health and LTC
Discharge planning responsibility
Identification of patients
Self care
Timely discharge evaluation
Discharge plan and self care evaluation
Remember the CMS discharge planning worksheet

Organ, Tissue and Eye Procurement 
Policy requirements
Board required
Organ donation training
Family notification
OPO Notification one call rule
CMS OPO memo

Surgical & Anesthesia Services 
Follow standards of care
Policies required
Supervision requirement
Preventing OR fires
OR register
Operative report
Required equipment
Anesthesia policies required 
Anesthesia and analgesia standards
Pre and post-anesthesia requirements
Anesthesia staffing
Documentation required
Intra-operative anesthesia record

Outpatient Services and proposed 2018 changes
No longer accountable to single individual
Policies and procedures
Meeting needs of patients
Outpatient orders 

Emergency Services 
Following standards of practice
Integrated into hospital PI
Qualified medical director
Policies required
Length of time to transport between departments

Rehabilitation and Respiratory Services 
Integrated into QAPI
Standards of care
Qualified director
Plan of care
Scope of services
Order needed
Policies required

Who Should Attend?
CEO’s, COO’s, Chief Nursing Officer,  Chief Medical Officer, Quality Managers, Consumer Advocate, Nurse Educators, Department directors, All Nurses, Risk Managers, Hospital Legal Counsel, Compliance Officers, Joint Commission Liaison, Director of Health Information, Case Managers, Chief Medical Officer, Nurse Educator, Pharmacists, Social Workers, Discharge Planners, PI Coordinator, Joint Commission Coordinator, Patient Safety Officer, Patient Safety Committee, Nurse Managers, Outpatient Director, Director of Rehab, Dieticians, Infection Control, Medication Management Team, Anesthesia and Surgery staff, PACU Director, Policy and Procedures Committee, Respiratory Therapy Director, Director of Radiology,  Infection Preventionist, Pharmacist, Pharmacy Director, and Staff Nurses.


Sue Dill Calloway 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 was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians, and other health care providers. Sue has authored over 100 books and numerous articles. She is a frequent speaker and is well known across the country in the areas of health care law, risk management, and patient safety. Sue has no real or perceived conflicts of interest that relate to this presentation.

7/23/2018 8:00 AM - 7/24/2018 12:00 PM
United States


Monday, 23 July 2018

7/23/2018 8:00 AM - 7/24/2018 12:00 PM
7/23/2018 8:00 AM
7/23/2018 8:00 AM - 7/24/2018 12:00 PM
7/23/2018 8:00 AM
7/23/2018 8:00 AM - 7/24/2018 12:00 PM
7/23/2018 8:00 AM

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