The Centers for Medicare & Medicaid Services (CMS) has issued many citations related to the
governing board, specifically contract management. The governing board of a hospital
oversees contracted services and ensures compliance with standards set forth by accrediting
bodies. This presentation will cover all contract requirements for hospitals under the CMS
Conditions of Participation and those accredited by the Joint Commission and DNV-GL.

This webinar will discuss the changes the Centers for Medicare & Medicaid Services (CMS)
made to the infection control standards in 2019 as well as the interpretive guidelines
developed in July 2022.

Attendees will learn how hospitals can comply with the regulation, including verifying
qualifications of the infection preventionist, having a hospital-wide antibiotic stewardship
program, and following nationally recognized infection control standards.

Additionally, this webinar will discuss the Centers for Disease Control and Prevention (CDC)
procedures for cleaning and disinfecting reusable medical devices, along with resources for
training. The Joint Commission standards on the Antibiotic Stewardship Program (ASP) will be
briefly discussed.

Any hospital that accepts Medicare reimbursement must comply with the Centers & Medicaid Services (CMS) Conditions of Participation (CoPs). The patient rights CMS CoPs manual has the highest number of deficiencies for hospitals.

This webinar will cover the CoPs Appendix A section on patient rights, which applies hospitals. Critical Access Hospital (CAH) Appendix W does not have a similar section. CAHs must provide a safe environment for patients.

Topics to be covered in this session include grievances, right to receive notice exercise of rights, informed consent, privacy, confidentially of medical records, directives, interpreters, abuse and neglect, plan of care, visitation rules, and support rights.

This webinar will cover the nursing services section from the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) manual. Many changes made to the hospital nursing chapter of the CoPs manual are still awaiting interpretive guidelines and survey procedures.

This program will discuss often cited areas of the CoPs manual regarding nursing care, including plans of care, staffing, policy changes, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services have been cited over 8,900 times, according to the most recent report.

Other past changes to the nursing section include timing of medications, standing orders, plan of care, verbal orders, blood transfusions, IV medication, self-administration of medications, and drug orders.

This program will also reference the ever-changing non-discrimination regulations of Section 1557 and will briefly cover other sections of the manual that impact nursing.

The MHA virtual roundtables are designed to provide healthcare compliance professionals and their teams the knowledge and tools needed to maintain compliance programs and to stay up-to-date with emerging regulatory developments. These bi-monthly meetings will feature brief presentations and engaging discussions.