CMS Hospital Conditions of Participation 2022 - Part 4: Nov. 30

Time: 12:00 PM


The series will be held virtually from 12-2 p.m.


IHA Members: $195 per organization 

Non-IHA Members: $245 per organization 

*Please note: The registration fee includes an unlimited number of connections within the same hospital or hospital system corporate office. 

Registrants will receive access to the program recording(s). 

Register Online

All hospitals must comply with the ever-changing Centers for Medicare & Medicaid Services Conditions of Participation (CoPs). This five-part webinar series designed for hospital and health system leaders will cover every section of the CMS Hospital Conditions of Participation (CoP) manual and include discussion of recent updates and interpretative guidelines. This program will review the most problematic standards and offer tips for a gap analysis to ensure compliance—and help you remain compliant with the CoPs.

This webinar series will review compliance gaps and 600 pages of final rules issued in 2020 through 2022 including:

  • Discharge planning standards; 

  • The Hospital Improvement Rule;

  • Changes to history and physical requirements;

  • System-wide quality assurance and performance improvement (QAPI) and infection control;

  • Autopsy;

  • Infection prevention and control;

  • Antibiotic stewardship program;

  • Medical records;

  • Nursing;

  • Outpatient; and

  • The role of non-physicians and ordering restraints/seclusion.


Part four of the series will include an overview of QAPI, medical staff, dietary, radiology, lab, UR, and facility services.

  • Quality Assessment and Performance Improvement (QAPI)

    • Program Requirements and Scope

    • Hospital Improvement Rule

    • Hospital CoPs, QAPI Survey Memo, QAPI Worksheet

    • Patient Safety, Medical Errors, Adverse Events

    • Quality Improvement Officer & Executive Responsibilities

    • 2020: QAPI new and revised tag numbers

  • Medical Staff

    • Evaluations and Privileges

    • Telemedicine – Hospital and Entity

    • H&P

    • Radiology

    • Standards of Practice

  • Radiological Services

    • Required Policies

    • Adverse Reaction to Agents

    • Safety Precautions

    • Secure Area for Films

    • Order Required

    • Staff Supervision

    • Signing of Radiology Reports

    • Radiopharmaceuticals on Off Hours

  • Laboratory Services and Look Back Program

    • Tissue Specimens

    • Blood Bank

  • Food and Dietary Services

    • Dietary Policies

    • Nutritional Assessment

    • Orders Written by Registered Dietitian or Nutrition Specialist

    • Therapeutic Diets and Patient Nutritional Needs

    • Diet Manual and Therapeutic Menus

    • Infection Control is Important!

  • Utilization Review

    • Utilization Review Committee

    • Admission or Continuous Stays

    • Medicare Patient Discharge Appeal Rights

    • Scope of Reviews

    • Notice Law and MOON Form

  • Physical Environment

    • Buildings And Equipment

    • Compliance with Performance Improvement

    • Life Safety Code

    • Trash

    • Emergency Preparedness

    • Emergency Power And Lighting

    • Emergency Gas And Water

    • Ventilation, Light, Temperature


  • 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.

Who Should Attend

  • Compliance

  • Quality Improvement

  • Risk Management

  • Nursing

  • Medical Staff

  • Radiology

  • Laboratory

  • Facilities Management

  • Emergency Management

  • Patient Financial Services

  • Nutrition

  • Utilization Review Committee Members

  • Operations

  • Health Information Management

  • Legal Affairs


Lena Browning, MHA, BSN, RNC-NIC, CSHA - Speakers
A nurse leader and accreditation specialist, Browning has more than 25 years of clinical leadership in acute care settings. She is an expert in CMS, The Joint Commission and state regulations and has performed system-wide tracers for continuous readiness and patient safety. Browning has coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in effective compliance and performance improvement strategies. Throughout her career, she has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence across healthcare settings.