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CMS CoPs Standards for Hospitals and Proposed Changes: Nursing Update 2020 – Webinar

November 5, 2020 @ 9:00 am - 11:00 am

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Did you know there were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) that went into effect November 29, 2019 with changes in 2020? Did you know there were over eighteen CMS survey memos of importance to nursing in the recent past? The final changes were in the Hospital Improvement Rule. It covers  plans of care, staffing, policy changes, when a RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement and more.

Did you know that CMS has issued deficiency reports which includes which are the most problematic standards for hospitals? Did you know that nursing services has been cited over 5,635 times according to the most recent report? This is a must attend program for any chief nursing officer, clinical nurse or nurse supervisor or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. This must attend program and will discuss the deficiencies and how hospitals can ensure compliance.

Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don’t be caught off guard and put your hospital’s reimbursement at risk. If a surveyor showed up at your door tomorrow, would you be prepared?

CMS made previous revisions to IV medication administration, blood transfusion, safe injection practices, compounding, beyond use date (BUD) and implemented safe opioid standards. Hospitals are still struggling with how to comply with these complicated standards especially the safe opioid interpretive guidelines.

There are many changes in the past to this section include timing of medications, standing orders, soft wrist restraints and restraint reporting, plan of care, verbal orders, blood transfusions, IV medication, compounding, BUD, antibiotic stewardship program, safe injection practices, self administration of medications and drug orders. CMS has issued the final worksheets on QAPI, discharge planning and infection control which should be on the radar screen of all department managers especially because there are changes in 2020 in all these sections. There are also proposed changes to the infection control worksheet which will be discussed.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV GL Healthcare must also follow these regulations.

The program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as the revised discharge planning standards, medication standards, revised history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols. CMS starting issuing deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.


  • Recall that CMS has a section on nursing services that every hospital must follow even if accredited
  • Describe that all medications must be administered within three different time frames
  • Discuss that nursing care plans are a frequently cited area by CMS
  • Recall that all verbal orders must be signed off and need to include both a date and time
  • Recall that there is a focus on safe injection practices by CMS

Who Should Attend:

Chief nursing officer, all nurses, nurse managers, nurse supervisors, nurse educators, HIM staff, compliance officer, medical staff coordinator, risk manager, patient safety officer, senior leadership,  documentation specialist, hospital legal counsel, QAPI director, Joint Commission coordinator, regulatory officers, legal counsel, chief operating officer, chief medical officer, physicians, education department staff, board members, director of health information management, audit staff, and others responsible for compliance with hospital nursing regulations including documentation compliance.


Laura Dixon, BS, JD, RN, CPHRM
Healthcare Risk Education and Consulting, LLC