CMS Hospital Surgery, Anesthesia, and PACU Conditions of Participation Requirements 2022

Lena Browning
From: May 17, 2022 - To: Dec 31, 2022
Recorded Webinar


This program will cover the CMS hospital CoP standards for surgery, anesthesia, and PACU. Every hospital that accepts Medicare and Medicaid must follow these standards and they must be followed for all patients.

Some of the important CMS memos that impact the provision of care in the OR arena and discuss safe injection practices and infection control breaches with IV medications will be discussed. Guidance from ISMP and CDC will also be provided.

Another topic to be covered is the changes to H&P that went into effect in November 2021.  Some of the changes include the options for hospitals to elect to assess healthy outpatients undergoing surgery or a procedure instead of an H&P.

This program will go over the number of reported CMS deficiencies and types received by hospitals. This has many important issues such as informed consent, H&Ps, and safe injection practices.

The many standards required by the surgery department and anesthesia will be addressed, including required policies, the current CMS guidelines, interpretive guidelines regarding pre-anesthesia evaluations, post-anesthesia evaluations, and anesthesia services.

Hospitals are required to have many policies including one on specific clinical situations involving anesthesia or analgesia. This includes interpretive guidelines on moderate sedation and deep sedation, including moderate and deep sedation done in other places like the emergency department and GI lab and patients who have ECTs.

The history and physical and informed consent form must be on the chart before surgery except in an emergency. An exception is made for young healthy outpatients if hospitals implement policies and follow the requirements.

Other areas to be covered include required surgical equipment, post-anesthesia assessment, and Joint Commission standards related to surgery and anesthesia.

Learning Objectives:-

  • Recall that there are several policies and procedures required by CMS related to surgery and anesthesia services
  • Describe that CMS has a section that addresses PACU requirements
  • Recall that CMS has a list of things that must be included in the OR register
  • Describe what information is required for informed consent and that it should be on the chart before surgery
  • Discuss the 48-hour requirements for the post-anesthesia evaluation of both inpatients and outpatients


Surgery and PACU

  • CMS manual and website
  • CMS Certification and Survey Memos
    • Humidity in the OR
    • Safe injection practices
    • Infection control breaches memo
    • CMS worksheets with a section on safe injection practices
  • Deficiency reports for Surgery, PACU, and Anesthesia
  • Surgical services chapter
  • Infection control in ORs
  • Equipment, temperature, humidity
  • Supervision in the OR
  • Scrub tech and circulators
  • Surgical privileges
  • Surgery policies required
  • Preventing OR fires and wrong site/side surgeries
  • History and physical 2021 & 2022 changes    
  • Informed consent and what must be included
  • OR register
  • Operative report requirements
  • Surgery equipment required
  • PACU standards
    • Monitoring of patients receiving opioids


  • Director of Anesthesia Services
  • Anesthesia versus analgesia
  • General, regional, MAC, topical, minimal sedation, moderate sedation
  • Rescue capacity
  • Other locations in a hospital where anesthesia is provided
  • QAPI
  • Director of Anesthesia responsibilities
  • Those who can administer anesthesia
  • Scope of practice for CRNA and Anesthesia Assistants
  • CRNA state exemption
  • Anesthesia Policies required
  • Pre-anesthesia assessment
  • Post-anesthesia evaluations
  • Consent and safety policies required
  • Documentation requirements
  • Intraoperative anesthesia record requirements

Appendix and Resources

Who Should Attend:-

  • Director of the OR and OR nurses/staff
  • PACU Nurse Manager/PACU nurses
  • Chief of Anesthesia
  • Anesthesiologist
  • CRNAs
  • Anesthesia Assistants
  • Medical Credentialing Staff
  • Patient Safety Officer
  • Risk Manager
  • Chief Nursing Officer (CNO)
  • Chief Medical Officer (CMO)
  • Chief Operating Officer (COO)
  • Chief Executive Officer (CEO)
  • OB Nurses and Nurse Director
  • Joint Commission liaison
  • Quality Improvement Director
  • Regulation and Accreditation Director
  • Nurse Educator
  • PI Director
  • Compliance Officer

Training Options

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