Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement Personnel, Risk Manager, Legal Counsel.

Part One: Accessing CMS & Documentation Requirements

Introduces key CMS Conditions of Participation requirements, including access to the CoPs manual, history and physical timing for elective surgery, verbal order authentication, and information blocking exceptions.

Part Two: Patient Rights & Restraint Policies

Examines patient rights and safety standards related to restraints, grievance processes, interpreter services, and non-physician practitioner authority.

Part Three: Medications, Orders & Nursing Plans

Covers medication administration timing, order and protocol approval, nursing care plan documentation, pharmacy safety, and opioid policy requirements.

Part Four: QAPI, Radiology & Facility Maintenance

Reviews QAPI program requirements, radiology policy and staffing standards, dietitian credentialing options, and facility maintenance expectations.

Part Five: Infection Control & Discharge Planning

Addresses infection prevention policies, post-acute care referral documentation, organ donation training, post-anesthesia assessment requirements, and new CMS obstetrical services standards.