Hospitals must follow the Centers for Medicare & Medicaid Services (CMS) conditions of participation (CoP) for all patients to receive Medicare and Medicaid reimbursement. The CoP are the specified requirements that must be upheld to address patient safety needs and services provided within a facility. Facilities included are acute care facilities, critical access hospitals, and health systems. CMS updates the CoP on a regular basis and it is important for leaders and staff to have an understanding of these requirements. Facilities that are accredited by the Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Center for Improvement in Healthcare Quality (CIHQ), or Det Norske Veritas (DNV) Healthcare must follow these regulations.

This program will review standards that have been updated since 2020. Essential standards that have changed or are at high risk for failure to uphold will be included. Examples are provider orders, medication management and administration, blood administration, nursing services and use of agency, nurse staffing, responsibilities of nursing leaders, discharge planning, visitation, and grievances.

The program will additionally cover sections in the hospital CoP manual that are most frequently cited as deficiencies during accreditation surveys. These areas of risk include infection prevention and control, antibiotic stewardship, Emergency Medical Treatment and Labor Act (EMTALA), restraints and seclusion, and suicide prevention.

Performance improvement and quality strategies will also be discussed. Gap assessments will be included for all levels of staff. Best practices and preparation for surveys will also be discussed.

Webinar Objectives

This program will provide an overview of CMS CoP requirements for hospitals, including recent updates and areas frequently cited as deficiencies. Recommendations for survey readiness will be addressed.

Webinar Agenda

Introduction to CMS hospital CoPs

CoP sections at risk for deficiencies:

• Provider orders
• Medication management and administration
• Blood administration
• Nursing services and use of agency staff
• Nurse staffing
• Responsibilities of nursing leaders
• Discharge planning
• Visitation
• Grievances

Frequently cited areas of deficiencies:

• Infection prevention and control
• Antibiotic stewardship
• Emergency Medical Treatment and Labor Act (EMTALA)
• Restraints and seclusion
• Suicide prevention
• Gap assessments and survey readiness
• Conclusion

Webinar Highlights

After completion of this program, the participant will be able to:

• Identify the importance of CoP compliance in a hospital setting
• Describe the areas of risk and commonly cited deficiencies in the CoP standards
• Discuss strategies for conducting a gap assessment and preparing for survey

Who Should Attend

• Nursing leaders, including Chief Nursing Officer, directors, managers, supervisors
• Bedside nurses and nurse educators
• Medical leaders, including Chief Medical Officer, chief of staff
• Physicians, physician assistants, nurse practitioners, medical staff coordinator
• Hospital administration, including Chief Executive Officer, Chief Operating Officer
• Compliance officer, patient safety leaders, risk manager, legal counsel, regulatory and accreditation leader
• Quality and performance improvement department leaders and staff, infection control staff, documentation compliance
• Health information leaders and staff
• Board members