CMS COPs 2023 Updates

OVERVIEW

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.

LEARNING 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.

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

AREAS COVERED

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

WHO WILL BENEFIT?

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

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Email: [email protected]

Call: +1-855-202-3299

Kim Maryniak

PhD, MSN, BN, RNC-NIC, NEA-BC

About speaker

Kim Maryniak, PhD, RNC-NIC, NEA-BC has over 33 years of nursing experience in medical/surgical, psychiatry, pediatrics, progressive care, long-term care, and adult and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, manager, director, and chief nursing officer.

Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta in 1989. She achieved her Bachelor in Nursing through Athabasca University, Alberta in 2000, her Master of Science in Nursing through University of Phoenix in 2005, and her PhD in Nursing through University of Phoenix in 2018.

Kim is certified in Neonatal Intensive Care Nursing and as a Nurse Executive, Advanced. She is active in the American Nurses Association and American Organization of Nurse Leaders. Her current and previous roles include nursing leadership, research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.