CMS Nursing Conditions of Participation for Hospitals: 2018 Update

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, Feb. 15, 2018
9 - 11 a.m.

Register on or before Friday, Feb. 9, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

This webinar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from the MHA Management Services Corporation.


Anyone involved with compliance regulations and standards, including but not limited to CMOs, CNOs, physicians, nurses, quality improvement staff, risk managers, pharmacy staff, compliance officers and legal counsel, ethics committee members, consumer advocates, TJC liaisons, safety officers, behavioral health and psychiatric staff, and case managers.

The following program content was provided by the speaker.


Recently, there has been increased scrutiny and surveillance to make sure all hospitals are in compliance with the Centers for Medicare & Medicaid Services Conditions of Participation. Every hospital that accepts Medicare or Medicaid must be in compliance with these regulations and interpretive guidelines.

This program will cover the nursing services section in the hospital CoP manual. Discussions will include the significant changes CMS has made to IV medication administration, blood transfusion, safe injection practices, compounding, beyond use date and implemented safe opioid standards. This program also will reference other sections that nurses should be aware of, including medication standards, verbal orders, history and physicals, visitation, restraint and seclusion, grievances, discharge planning standards, and privacy and confidentiality.


  • identify the CMS nursing services that every accredited hospital must follow
  • describe the medications that must be administered within three different time frames
  • identify the sections of frequently cited nursing care plans, including recent CMS changes to those plans
  • discuss the various CMS requirements for verbal orders


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway is a nurse attorney and president of Patient Safety and Healthcare Consulting and Education Company. Calloway was the past vice president of legal services at a community hospital, in addition to being the privacy officer and the compliance officer. Calloway served as the director of risk management and health policy for more than eight years at the Ohio Hospital Association. She also was the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus, Ohio, for five years. She frequently lectures on legal and risk management issues and writes numerous publications. Calloway is a 1996 recipient of PESI HealthCare’s Excellence in Education award.