The CMS Hospital Conditions of Participation (CoPs) 2022

Laura A. Dixon
From: Jul 11, 2022 - To: Dec 31, 2022
Recorded Webinar


This five-part webinar series will cover the entire CMS Hospital CoP manual – Appendix A. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that apply to their department.  This program will discuss the most problematic standards and how the hospital can do a gap analysis to assist in compliance with the CoPs.

This program will include the 2020 changes and where the gaps continue – the absence of interpretive guidelines and survey procedures. This includes:

  • Changes to history and physicals
  • System-wide QAPI and infection control
  • Autopsy
  • Discharge planning
  • Infection prevention and control
  • Antibiotic stewardship program
  • Medical records
  • Nursing
  • Outpatient
  • The role of non-physicians and ordering restraints/seclusion.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. The manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital-owned departments. Facilities with deemed status accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV Healthcare must follow these regulations. 

There are sections on medical record services, dietary, utilization review, emergency department, surgical services, anesthesia, PACU, medical staff, nursing services, lab, outpatient department, rehabilitation, radiology, respiratory, physical environment, pharmacy, infection control, organ and tissue, patient rights and discharge planning.

The interpretive guidelines serve as the basis for determining hospital compliance and though many of the changes from 2020 continue to have interpretive guidelines pending, along with survey procedures, hospitals are still expected to comply with the regulations.  There have been significant changes and many important survey memos issued also.

CMS has worksheets for assessing compliance with the QAPI, discharge planning standards, and infection control.  Though no longer utilized by State and Federal surveyors, the worksheets are available as excellent self-assessment tools for hospitals. These 3 worksheets will be covered.

Most recent changes and requirements in the requirements of the medical record, specific access to medical records, and blocking of information will be addressed.  Other changes to the majority of the manual have occurred in the recent past.  All changes will be discussed.

Part One of Five:- (Available for All Day)

Introduction, CMS Survey Memos, surveyor training material, hospital deficiency reports, CMS 3 worksheets, CDC vaccine information, OCR 1557, required education, Board and Medical Staff, budget, contracts, emergency services, medical records, standing orders, H&Ps


  • Discuss how to locate a copy of the current CMS CoP manual
  • Describe that a history and physical for a patient undergoing an elective surgery must not be older than 30 days and updated on the day of surgery
  • Discuss that verbal orders must be signed off by the physician along with a date and TIME
  • Describe the changes to medical record requirements, including interoperability and “blocking”.

The agenda will cover:-

Overview of the CMS Survey Process and Introduction

  • Introduction
  • General information and location of the manual
  • Hospital deficiency reports
  • Memos of interest to hospitals
    • Ligature risks, texting of orders, Legionella, Complaint manual, Insulin pens, infection control breaches, safe injection practices, ISMP, and medication guidelines
  • Three CMS Worksheets
  • CDC Vaccine Storage and handling
  • Non-Discrimination, Interpreters and Section 1557 ACA
  • CMS required education
  • Survey protocols
  • Survey team
  • Compliance with laws

Board and CEO

  • Board requirements
  • CMS by-laws
  • Appointment of the MS
  • Credentialing and Privileges
  • Medical staff and the board
  • Single medical staff or unified integrated MS
  • Privileging others such as PharmD, podiatrist, RD, etc.
  • Telemedicine
  • CEO requirements
  • Care of patients
  • Plan and budget
  • Contracted services
  • Emergency services
  • Autopsy changes
  • Board responsibilities for infection control and QAPI if chosen system-wide

Emergency Services

  • EMTALA is a separate manual
  • Need for P&P
  • Qualified RN to assess patients
  • Basic patient care requirements

Medical Records (Health Information Management)

  • Access to medical records updates and new penalties
  • Organization and staffing
  • Confidentiality of records
  • Content of records
  • Legibility requirements
  • Signature stamps and guidelines
  • Verbal orders
  • Standing orders
  • Authentication
  • Informed consent mandatory and optional elements
  • H&P and changes for healthy outpatients
  • Discharge summary
  • Interoperability of medical records
  • Information blocking

Part Two of Five:- (Available for All Day)

Patient Rights: Advance Directives, Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse, and Neglect, Confidentiality, Restraints, and Visitation


  • Recall that CMS has restraint standards that hospitals must follow
  • Describe that a hospital must have a grievance policy and procedure in place
  • Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
  • Describe how non-physician practitioners – PAs, NPs – can order restraints

Patient Rights

  • Final changes
  • Patient's timely access to their medical records
  • Notice of rights to be provided
  • Designation of representative
  • IM notice – Medicare patients
    • OCR Section 1557
    • Interpreters
    • Low health literacy
    • Grievances and procedure
    • “7-Day” rule
    • Understanding of patient advocate/support person
    • Advance directives
    • Informed consent
    • Patient representative
    • Family member and doctor notification
    • Privacy and confidential
    • Care in a safe setting
    • Safety of behavioral health patients
    • Ligature risks
    • Freedom from abuse and neglect
    • Criminal background checks
    • Access to medical records
    • Privacy and confidentiality memo
    • PA ordering restraints
    • Restraint and seclusion- types and requirements
    • Less restrictive methods and alternatives
    • Plan of care
    • Documentation
    • One-Hour rule
    • Staff education
    • Visitation rights

Part Three of Five:- (Available for All Day)

Nursing and Pharmacy


  • Describe which medications must be given time and within one of three blocks of time
  • Recall that all orders/protocols should be approved by the Medical Staff and order entered into the medical record and signed off
  • Recall that a nursing care plan must be in writing, started soon after admission, and maintained in the medical record
  • Discuss patient safety issues with compounding pharmacies
  • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Nursing Services

  • Organized and 24-hour services
  • Director of Nursing/CNO
  • Nurse at bedside
  • Director of nursing (CNO)
  • Staffing and patient safety
  • Nursing care plan
  • Agency nurses
  • Medication administration and safe opioid use
  • Safe injection practices and compounding
  • Policies and procedures for medication administration
  • Timing of medication administration
  • Assessment and monitoring of patients
  • High later medications
  • Compounding of medications
  • Need for physician order
  • Standing and preprinted order sets
  • Verbal orders
  • IV medications and blood administration
  • Staff training and competency
  • Self-administration of medication
  • Reporting medication errors and ADEs

Pharmaceutical Services

  • Antibiotic stewardship program requirements
  • Revised CDC Core Elements for ASP
    • Use of compounding pharmacies
    • Obtaining from compounding pharmacy v. manufacturer or registered outsourcing facility
    • BUD, packaging, and labeling of medications
  • The requirement to follow professional standards of care
  • Best practices recommendations such as ISMP and ASHP
  • Preparing CSPs outside the pharmacy
  • Services to meet patient needs
  • Storage of drugs
  • Pharmaceuticals available off-hours
  • Floor stock
  • P&P to minimize drug error
  • High Alter medications
  • Reporting of Medication events
  • Alerts and recalls
  • Pharmacy Director
  • Staff qualifications
  • Pharmacy records
  • First dose review
  • Compounding pharmacy
  • Definitions of medication errors, ADE
  • Notification of physician
  • Policies required and training on policies
  • Pharmacy requirements
  • Storage and security of medications
  • Outdated or mislabeled medications or unusable drugs
  • Drug interactions and side effects
  • PI requirements for adverse drug events
  • Medication shortages

Part Four of Five:- (Available for All Day)

QAPI, Medical Staff, Dietary, Radiology, Lab, UR, and Facility Services


  • Recall the requirement for and elements of a QAPI program
  • Describe the need for radiology policies, including one on radiation safety and the need for qualified staff
  • Discuss the new option of credentialing the dietician to order diets – if allowed by the state
  • Describe the need for a facility maintenance program to include water management

Quality Assessment and Performance Improvement

  • PI program requirements
  • Final changes
  • Revised tag numbers
  • Tracking of medical errors and adverse events
  • Identifying opportunities for improvement
  • Patient safety

Medical Staff, Board, and CEO

  • Medical staff and Board requirements
  • Shared medical staff
  • MS by-laws
  • Appraisal of MS
  • Accountability of MS for quality of care
  • Credentialing and privileging
  • Telemedicine – hospital, and entity-based
  • Hospitals are part of a system – shared medical staff
  • History and physicals

Radiological Services

  • Radiation exposure
  • Standard of care
  • Scope and complexity
  • Therapeutic radiology
  • Adverse reaction to agents
  • Safety precautions
  • Shielding of patients
  • Supervision of staff
  • The signing of radiology reports
  • Radiopharmaceuticals on off-hours

Laboratory Services and Look Back Program

  • Lab services
  • Tissues specimens
  • Blood bank
  • Recordkeeping
  • Look back program

Food and Dietary Services

  • Diets and menus
  • Credentialing RD or nutrition specialist to write diet orders
  • Patient nutritional needs
  • Diet manual and therapeutic menus
  • Qualified director required
  • 7 required dietary policies
  • Nutritional assessment
  • Order required
  • Therapeutic diets and nutritional needs

Utilization Review

  • Composition of UR committee
  • Admission or continuous stays
  • Medicare patient discharge appeal rights
  • UR plan
  • Scope and frequency of reviews
  • Notice Law and MOON form

Physical Environment

  • Buildings and equipment
  • Facility and building maintenance
  • Security factors to consider – including ligature risks
  • Emergency systems and life safety code
  • Trash
  • Emergency Preparedness
    • Emergency power and lighting
    • Emergency gas and water
    • Ventilation, light, temperature

Part Five of Five:- (Available for All Day)

Infection Prevention, Discharge Planning, Organ Procurement, Surgery, PACU, Anesthesia, Emergency Services, Outpatient, Rehab, and Respiratory


  • Discuss that CMS requires many policies in infection prevention and control
  • Recall that patients referred to a post-acute care provider – PAC – must be given a list in writing of those available and this must be documented in the medical record
  • Describe that all staff must be trained in the hospital’s policy on organ donation
  • Recall that CMS has specific things that are required to be documented in the medical record regarding the post-anesthesia assessment

Infection Prevention and Control

  • Infection preventionist responsibilities and role in the antibiotic stewardship program
  • IP appointed by the board
  • Policies and procedures required
  • Mitigation of risks
  • Duties and responsibilities of the leader of the Antibiotic Stewardship program
  • Scope and complexity of the program
  • Multi-hospital/Unified program
  • Mandatory training

Discharge Planning

  • Discharge planning worksheet
  • Identification of patient needs
  • Discharge planning and evaluation
  • Information provided to the patient
  • Discharge planning responsibility
  • Identification of patients
  • Transfers
  • Referrals
  • Self-care
  • Timely discharge evaluation
  • Discharge plan and self-care evaluation

Organ, Tissue, and Eye Procurement

  • Policy requirements
  • OPO agreement required
  • Organ donation training
  • Family notification
  • OPO Notification one-call rule

Surgical, PACU & Anesthesia Services

  • Policies required
  • Organized and staff service
  • Surgical tasks and privileges
  • Preventing OR fires
  • H&P
  • Consent
  • OR Register
  • Operative report
  • Required equipment
  • PACU
  • Anesthesia policies required
  • Anesthesia and analgesia standards
  • Pre- and post-anesthesia requirements
  • Anesthesia organization and staffing
  • State exemptions - CRNAs
  • Documentation required
  • Intra-operative anesthesia record

Outpatient Services and final changes

  • Changes in accountability
  • Policies and procedures
  • Meeting needs of patients
  • Outpatient orders
  • Documentation of care given in the OP department
  • Orders required
  • Department director job description and responsibilities

Emergency Services

  • Services must meet patient needs
  • Following standards of practice
  • Integrated into hospital PI
  • Qualified medical director
  • Policies required
  • Training required
  • Length of time to transport between departments

Rehabilitation and Respiratory Services

  • Integrated into QAPI
  • Standards of care
  • Qualified director
  • Plan of care
  • Scope of services
  • Order needed
  • Policies required

Who Should Attend?

CEOs, COOs, Chief Nursing officers, Chief Medical officers, Quality Managers, Consumer Advocate, Nurse Educators, Department directors, All Nurses, Risk Managers, Hospital Legal Counsel, Compliance Officers, Joint Commission Liaison, Director of Health Information, Case Managers, Pharmacists, Social Workers, Discharge Planners, PI Coordinator, Patient Safety Officer, Patient Safety Committee, Nurse Managers, Outpatient Director, Director of Rehab, Dieticians, Infection Control, Medication Management Team, Anesthesia and Surgery staff, PACU Director, Policy and Procedures Committee, Respiratory Therapy Director, Director of Radiology, Infection Preventionist, Pharmacist, Pharmacy Director

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