CMS Hospital CoPs Made Easy - Utilization Review, Quality, Radiology and Other: July 17

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 webinar will focus on recent regulatory changes and CoP requirements related to:

  • Hospital quality assessment and performance improvement (QAPI) program requirements;
  • Radiological services, including CMS’ focus on decreasing radiation exposure;
  • Laboratory services and the look back program, including revisions to blood bank standards, which may require changes to hospital policies and procedures;
  • Food and dietetic services, including changes permitting registered dietitians to independently order patient diets;
  • Utilization review;
  • Federal Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act and the Medicare Outpatient Observation Notice (MOON) Form; and
  • Physical environment and maintenance, which are areas of increased focus in CMS surveys.

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 fourth webinar in the series will cover:

  • Quality Assessment and Performance Improvement (QAPI)
    • Proposed 2018 changes and recent CoP revisions
    • Hospital performance improvement program requirements and the Centers for Medicare & Medicaid Services (CMS) QAPI Worksheet
    • Tracking medical errors and adverse events
    • Identifying opportunities for improvement
    • Patient safety
  • Radiological Services
    • 2015 memo and CoP standards rewrite on decreasing harmful exposure to ionizing radiation
    • Standards specifying policy and procedure requirements, safety precautions for patients and personnel, and consistent monitoring of personnel exposure and equipment hazards
    • Order and record requirements
  • Laboratory Services and Look-Back Program
    • The requirements that lab services meet patient needs and national standards and receive proper documentation
    • Tissue specimens
    • Blood bank standard revisions
    • Patient notification standards
  • Food and Dietetic Services
    • Recent CoP changes such as permitting registered dietitians or nutritional specialists to independently order patient diets
    • Seven required dietary policies, including diet manual and therapeutic diet menus, frequency of meals, system for diet ordering and patient tray delivery, accommodation of non-routine occurrences, integration of food and dietetic services into QAPI and infection control programs, and acceptable hygiene practices
    • Hospital dietetic program standards
    • Nutritional assessment and diet orders
    • CMS survey procedures
  • Utilization Review (UR)
    • Connection of UR to recovery audit contractors
    • Composition of UR committee
    • Scope of UR reviews
    • Survey procedures
  • Federal Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act and Medicare Outpatient Observation Notice (MOON) Form
    • The requirement that patients be notified if they are placed in an outpatient observation bed for more than 24 hours
    • Time frame for patients and staff to sign the CMS MOON form
  • Physical Environment and Maintenance
    • The requirements that apply to all hospital locations, satellites and campuses
    • The requirements that buildings and equipment be accessible, address age-related safety hazards and risks, and provide adequate security
    • Current topics, including ligature risk and power strips
    • Emergency preparedness, trash, fire safety, ventilation, light, and temperature


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

  • Understand the roles and responsibilities of hospital leaders, medical staff and administrative officials in quality improvement.
  • Describe how the Centers for Medicare & Medicaid Services uses the Quality Assessment Performance Improvement Worksheet to assess hospital compliance with CoPs.
  • Discuss the connection between utilization review CoPs and recovery audit contractors.

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.