Nursing: CMS CoP Standards for Hospitals 2024

Recorded Webinar | Laura A. Dixon | From: Jul 03, 2024 - To: Dec 31, 2024

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 with Deemed Status accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.

There were some changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020. However, many of those changes are still awaiting interpretive guidelines and survey procedures.

This program will discuss the often-cited areas of the CoP manual involving nursing care:  plans of care, staffing, policy changes when an RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services have been cited over 8,900 times according to the most recent report.

Other changes in the past 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 briefly mention other sections of the manual that impact Nursing and for which nurses should be aware.

Learning Objectives:-

  • Recall that CMS has a section on nursing services that every hospital must follow even if accredited
  • Describe the three different timeframes for which all medications must be administered
  • Discuss that nursing care plans are a frequently cited area by CMS
  • Recall the requirements for verbal orders


  • Introduction to the CMS hospital CoPs manual
  • CMS deficiency reports
  • 2020 changes to the Nursing section
  • Recent memos affecting nursing
    • Ligature risks
    • Discharge Planning
  • Non-Discrimination and Nursing
  • Conditions of Participation - Nursing
  • Nursing Services and 24-hour services
  • RN on duty – recent update
  • Organizational chart and nursing
  • Chief Nursing Officer (CNO) responsibilities & requirements
  • Staffing and delivery of care
  • 24-hour nursing services and supervision
  • RN to evaluate to care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Assignment of patient care
  • Agency nurse requirements
  • Outpatient departments
  • Medication administration
  • The order required for all medications
  • Requirements for complete drug order
  • Medication Safety and “5 Rights”
  • Safe Injection Practices
  • Three medication timing changes
  • Safe Opioid use
  • Standing orders and protocols
  • Verbal orders
  • Blood transfusions and IV medication changes
  • Reporting blood administration and medication errors
  • Home and Self-administered medications
  • CAH Nursing requirements
  • Other manual sections of importance to Nursing
    • Restraint and seclusion
    • Medication Policies
    • Visitation
    • Discharge planning revised standards

Appendix and Resources

Who Should Attend?

  • Chief nursing officer
  • All nurses
  • Nurse managers/supervisors
  • Nurse educators
  • Compliance officer
  • Chief of medical staff
  • Risk manager
  • Patient safety officer
  • Senior leadership
  • Joint Commission coordinator
  • Regulatory officers
  • Physicians
  • Audit staff

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