CMS Hospital Conditions of Participation 2022 - Part 5: Dec. 14

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 five (the final session) will provide an in depth review of infection control; discharge planning; organ, tissue and eye procurement; surgery; PACU; anesthesia; emergency services; outpatient; rehab; and respiratory services.

  • Infection Prevention and Control and Antibiotic Stewardship Program

    • Hospital Wide Programs

    • Scope and Complexity

    • Leadership’s Responsibilities

    • Multi-Hospital System Program

    • Responsible Individual

    • Infection Control Worksheets

  • Discharge Planning

    • Final discharge planning worksheet

    • Final changes to discharge planning  and many 2020 changes

    • Discharge plan and self-care evaluation

    • Discharge planning responsibility

    • Transfers

    • Referrals

    • Self-care

    • Timely discharge evaluation

    • CMS discharge planning worksheet

  • Organ, Tissue, and Eye Procurement

    • Policy requirements

    • Organ Donation Training

    • Family Notification

    • One Call Rule

    • CMS Organ Procurement Organization memo

  • Surgical & Anesthesia Services

    • Required Surgical and Anesthesia Policies

    • Supervision Requirement

    • H&P

    • Consent

    • Operating Room Register

    • Operative Report

    • Required Equipment

    • PACU

    • Anesthesia and Analgesia Standards

    • Pre and Post-Anesthesia Requirements

    • Staffing

    • Documentation

    • Intra-Operative Anesthesia Record 

  • Outpatient Services and Final Changes

    • No longer accountable to single individual

    • Policies and procedures

    • Meeting needs of patients

    • Outpatient orders

    • Documentation of care given in the OP department

    • Orders required

    • Department director job description and responsibilities

  • Emergency Services

    • Practice Standards

    • Integrated into Hospital Performance Improvement

    • Qualified Medical Director

    • Required Policies and Training

    • Length of Time to Transport Between Departments

    • EMTALA

  • Rehabilitation and Respiratory Services

    • Policies

    • Qualified Director

    • Standards of Care

    • Integrated into QAPI

    • Plan of Care

    • Scope of Services


  • 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.

  • 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 and changes to the standards.

Who Should Attend

  • Compliance

  • Quality Improvement

  • Risk Management

  • Nursing

  • Medical Staff

  • Emergency Department

  • Rehabilitation

  • Operations

  • Facilities Management

  • Medical Records

  • 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.