CMS Hospital CoPs Made Easy - Infection Control, Discharge, Surgery and Other: July 26

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.

This last webinar in the five-part series will explore key concepts within:

  • Infection control;
  • Discharge planning, including recent changes and proposals that significantly modify existing hospital discharge processes and forms;
  • Hospital policy requirements and agreements related to organ, tissue and eye procurement, and the one-call rule;
  • Standards of care, personnel roles and responsibilities, and documentation requirements related to surgical and anesthesia services;
  • The integration of inpatient and outpatient services and outpatient orders;
  • Emergency services standards; and
  • Rehabilitation and respiratory services, including written care plans and staff qualifications.

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.


The fifth webinar in the series will cover:

  • Infection Control (IC)
    • Proposed standards updating both hospital antibiotic stewardship programs and infection preventionist qualifications
    • Hospital IC policies
    • Centers for Medicare & Medicaid Services (CMS) Infection Control Worksheet
    • Active surveillance programs
    • Safe injection practices
    • Infection control officer, chief executive officer, chief nursing officer, and medical staff responsibilities
  • Discharge Planning
    • 2013 CoP rewrite and anticipated 2018 Improving Medicare Post-Acute Care Transformation (IMPACT) Act changes
    • Final CMS Discharge Planning Worksheet
    • Hospital discharge planning requirements, including the requirement that 48 hours before patient discharge, the hospital determine the patient’s post-hospital needs and create a discharge plan for any necessary additional services, special equipment or modifications at home
  • Organ, Tissue and Eye
    • Hospital organ donation policy requirements, including board involvement, staff training and family notification
    • Necessary agreements with organ procurement organizations (OPOs), tissue banks and/or eye banks
    • OPO notification one-call rule
  • Surgery and Post-Anesthesia Care Unit (PACU)
    • Standards of care
    • The requirements that surgery policies specify patient care requirements, personnel duties and provisions for the mitigation of patient hyperthermia, exposure to infectious or biomedical waste, and fires in the operating room
    • Supervision by qualified personnel
    • Privileging standards and roster
    • Informed consent guidance
    • Surgery equipment
    • PACU requirements, assessments and post-operative monitoring
    • Surgical register
    • CMS operative report
  • Anesthesia
    • Required anesthesia policies
    • Monitored anesthesia care
    • Anesthesia and analgesia standards
    • Pre- and post-anesthesia requirements
    • Anesthesia organization and staffing
    • Required assessment and documentation
    • Intra-operative anesthesia record
  • Outpatient Services
    • Policies and procedures
    • Integration with inpatient services
    • Recent changes to outpatient tags
    • Outpatient orders
  • Emergency Services
    • Standards of care
    • Integration with quality and performance improvement (QAPI) and other hospital departments
    • CMS survey preparation tips
  • Rehabilitation and Respiratory Services
    • Staff qualifications specified by medical staff and state law
    • Standards of care and scopes of practice in hospital policies
    • Integration with QAPI
    • Written care plan


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

  • Outline the Centers for Medicare & Medicaid Services’ (CMS) new infection control policies.
  • Specify new discharge planning assessments and documentation requirements.
  • Utilize the CMS discharge planning and infection control worksheets.
  • Describe organ procurement compliance strategies.

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.