CMS Hospital CoPs Made Easy - Governance, Records and Surveys: June 12

Time: 12:00 PM




IHA members: $195 per webinar connection
Non-IHA members: $250 per webinar connection
A 15 percent series registration discount is available. Click the registration link below for additional details.

Register Online

If a surveyor from the Centers for Medicare & Medicaid Services (CMS) showed up at your hospital tomorrow, would you be prepared?

Take part in a five-session webinar series focused on the current CMS hospital Conditions of Participation (CoP) manual, interpretative guidelines and compliance resources. In each session, nurse attorney Sue Dill Calloway will explore CMS survey processes and areas of focus, along with compliance strategies to help you prepare.

The first webinar in the series will focus on:

  • An introduction to CMS, including CoPs, survey processes, CMS compliance resources, and regulatory changes;
  • Governance CoPs, including the roles and responsibilities of the board, the chief executive officer and the medical staff; and
  • The Medical Records chapter, including a summary of hospital requirements related to content, authentication timeframes, documentation of verbal orders, and informed content.

Participants will also review recent CMS guidance on current issues like ligature risk, texting of orders, Legionnaires' disease, and the safe use of opioids.

Take advantage of this opportunity to train your entire team for the cost of one registration. An unlimited number of staff may participate using one phone line and internet connection. Attend the webinar with your colleagues and use the program as a springboard to discuss your organization’s implementation strategies.


This first webinar in the series will cover:

  • Centers for Medicare & Medicaid Services (CMS) Resources and  Survey Processes
    • Locating the CoP manual and resources on the CMS website
    • Recent CoP changes regarding medical staff, board, radiopharmaceuticals, dietitian-ordered diet, ordering outpatient services, and separate and unified medical staff
    • Common deficiencies in order sets, protocols and standing orders
    • CMS memos on ligature risks, texting of orders, privacy, Legionella, confidentiality, rehabilitation, timing of medications, medication errors, humidity, reporting to internal performance improvement, Ebola, worksheets, Luer misconnection, safe opioid use, safe injection practices, infection control breaches, organ procurement contracts, and deficiency, among others
    • Revised hospital worksheets (i.e. infection control, performance improvement and discharge planning)
    • Survey team and survey processes
  • Governing Body CoPs
    • Board requirements and by-laws
    • Chief executive officer requirements
    • Organizational plan and budget, care of patients, contracted services, and emergency services
    • Medical staff appointments, credentialing and privileging tracers, and interactions with the board, among other topics
    • Telemedicine
  • Medical Staff
    • Medical staff by-laws
    • Credentialing and privileging
    • Appraisals and accountability for quality of care
    • Medical staff changes
    • History and physicals
    • Autopsy requirements
  • Medical Records (Health Information Management)
    • Proposed 2018 changes
    • Substance use disorder (drug and alcohol) records
    • Organization and staffing
    • Confidentiality and record content
    • Legibility requirements
    • Authentication
    • Mandatory and optional elements of informed consent
    • History and physical
    • Verbal orders
    • Signature stamps and guidelines
    • Discharge summary


Upon completion of this program, participants will be able to:

  • Navigate the Centers for Medicare & Medicaid Services (CMS) website, and obtain the current hospital CoP manual, interpretative guidelines and CMS memos.
  • Outline CMS survey processes and focus areas.
  • Identify compliance strategies for CMS requirements related to hospital governance and medical records.

Who this is for

This webinar series is designed for anyone involved with or interested in regulatory compliance, including leaders and professionals in:

  • Administration
  • Finance
  • Operations
  • Clinical care
  • Compliance
  • Quality improvement
  • Risk management
  • Legal affairs
  • Facilities management
  • Board members
  • Government relations


Sue Dill Calloway, RN, MSN, JD, President, Patient Safety and Healthcare Consulting and Education

Sue has been a medico-legal consultant for over 30 years and is a long-time educator for healthcare providers. A frequent speaker, she is a nationally recognized expert on Centers for Medicare & Medicaid Services hospital CoP issues and well-known in the areas of healthcare law, risk management and patient safety. She has authored over 100 books and hundreds of articles.

Sue earned her Associate Degree in Nursing from Central Ohio Technical College and her Bachelor of the Arts, Bachelors of Science in Nursing, Master of Science in Nursing (summa cum laude), and Juris Doctorate (with honors) from Capital University.