CMS Hospital Conditions of Participation Made Easy 2019

July 31, Aug. 7, 14, 21 & 28

Noon-2 p.m. Central

This educational activity is jointly provided by AXIS Medical Education and The Texas Hospital Association.

Join us for this yearly review of the CMS Hospital Conditions of Participation (CoPs). 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 applies to their department. Hospitals have seen a significant increase in survey activity by CMS. This program will discuss the most problematic standards.
This program will also include the proposed changes in 2019. This includes changes to history and physicals, system-wide QAPI and infection control, discretion on when an autopsy is indicated, and the role of non-physicians in psychiatric hospitals.
The 2019 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.

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 the CMS 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; and
  • Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical record.
  • 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 dietitian 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; and
  • Recognize that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment; and
  • Recall that CMS has finalized the discharge planning workshop.

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.