The CMS Conditions of Participation (CoPs) 2025 (THA 3.25.25)

Date: March 25, 27, April 1, 3, 8, 10, 15, 17, 22, & 24, 2025
Time: 12:00 pm – 1:00 pm CST (March 27 will be from 12:00pm - 2:00pm)
Cost: $695 to NHA members (Per hospital, no charge for additional lines.)
Course Curriculum:
This ten-part online seminar series will cover a majority of the CMS Hospital CoP manual – Appendix A. It is an excellent way to educate everyone in your hospital on all the sections of the CMS hospital manual, especially ones that apply to their department.
Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Conditions of Participation. The manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital owned departments. Facilities with deemed status accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV Healthcare must follow these regulations.
Sections addressed include infection prevention and control and antibiotic stewardship program, QAPI, medical record services, dietary, utilization review, emergency services, surgical services, anesthesia, PACU, medical staff, nursing services, lab, rehabilitation, radiology, respiratory, physical environment, pharmacy, organ and tissue procurement, patient rights including restraint and seclusion, and discharge planning.
The interpretive guidelines serve as the basis for determining hospital compliance and though some changes from 2020 continue to have interpretive guidelines and survey procedures pending, hospitals are still expected to comply with the regulations. This program will include the 2020 changes, 2023 and 2024 updates and where some of the gaps continue – absence of interpretive guidelines and survey procedures, and any recent updates.
Learning Objectives:
Part 1 - Introduction, hospital deficiency reports, CMS Survey Memos of interest, compliance with laws including OCR 1557, required education, emergency services, and outpatient services.
• Discuss how to locate the current CMS CoP manual
• Describe essential requirements from recent memos, including texting of orders
• Describe the requirements of emergency services to be integrated into other services
• Discuss the necessary number and types of personnel for outpatient services

Part 2 - Patient Rights: Advance Directives, Giving Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, and Visitation, Restraint and Seclusion
• Describe the requirement for a hospital to have a grievance policy and procedure in place
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
• Describe the various patient rights to include providing consent, forming advance directives and visitation rights
• Recall that CMS has restraint standards that hospitals must follow

Part 3 - Nursing
• Describe which medications must be given timely and within one of three blocks of time
• Recall the requirements for a director of nursing for each hospital
• Recall that all order/protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Part 4 - Pharmacy and Pharmaceutical Services
• Recall the drug storage and pharmacy management requirements
• Discuss patient safety issues with compounding pharmacies
• Explain the several types of medication events
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Part 5 - Governing Body (Board), Medical Staff, Utilization Review
• Recall the requirements for an effective governing body and its respective responsibilities
• Discuss the board responsibilities for telemedicine providers
• Recall the necessary requirements for effective credentialing of providers
• Discuss the composition of the utilization review committee

Part 6 - Quality Assurance and Performance Improvement, Discharge Planning
• Recall the requirement for and elements of a QAPI program
• Discuss the governing body’s responsibilities for QAPI program
• Recall that patients referred a post-acute care provider – PAC – must be given a list in writing of those available and this must be documented in the medical record
• Discuss the requirement for a discharge evaluation and when requested – a discharge plan be developed

Part 7 - Medical Records
• Recall the requirements for a security risk analysis
• Describe the time limitations for a history and physical for an inpatient undergoing an elective surgery
• Describe the mandatory elements of informed consent
• Recall what must be included in any medical record
• Describe the four exceptions to information blocking

Part 8 - Surgery, PACU, Anesthesia and Organ Procurement
• Recall the required surgical policies
• Discuss recent updates to surgical consent requirements to include exams outside of designated procedure
• Recall that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment
• Describe that all staff must be trained in the hospital’s policy on organ donation

Part 9 - Laboratory, Radiology services, Dietary, Rehabilitation and Respiratory services
• Recall the requirement for adequate laboratory services
• Describe the need for radiology policies, including radiation safety and need for qualified staff
• Discuss the new option of credentialing the dietician to order diets – if allowed by the state
• Recall the requirements for optional services of rehab and respiratory services

Part 10 - Infection Prevention and Control and Antibiotic Stewardship Program, Plant and Physical Environment, Emergency Preparedness
• Discuss that CMS requires many policies in infection prevention and control
• Recall the duties and responsibilities of the infection preventionist and leader of the antibiotic stewardship programs
• Describe the need for facility maintenance program to include water management and ligature safety
• Recall the necessary training and testing for a hospital’s emergency preparedness program

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.

Speaker: Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Before joining Kaiser, she served as the director of facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Before joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff of the western United States

As a registered nurse and attorney, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.