The CMS Hospital Conditions of Participation (CoPs) 2022 - Part Five of Five-part Webinar Series

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CMS Hospital Conditions of Participation 2022 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.

Part Five of CMS Hospital Conditions of Participation 2022

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

Objectives:-

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

Agenda:-

Infection Prevention and Control

Infection preventionist responsibilities and role in the antibiotic stewardship program
Policies and procedures required
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
Organ donation training
Family notification
OPO Notification one call rule


Surgical, PACU & Anesthesia Services

Policies required
Surgical tasks and privileges
Preventing OR fires
H&P
Consent
OR register
Operative report
PACU
Anesthesia policies required
Anesthesia and analgesia standards
Pre- and post-anesthesia requirements
Anesthesia organization and staffing
Documentation required


Outpatient Services and final changes

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

Emergency Services

Services must meet patient needs
Qualified medical director
Policies required
Training required
Length of time to transport between departments
EMAIL


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?

CEO’s
COO’s
Chief Nursing Officer
Chief Medical Officer
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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