This document summarizes updates to the Conditions of Participation (CoPs) for hospitals from the Centers for Medicare and Medicaid Services (CMS). It discusses two Federal Register entries from 2012 and 2014 that modified the Code of Federal Regulations and State Operations Manual relating to various hospital CoPs. The 2012 update addressed topics like standing orders, medical staff leadership, order authentication, and critical access hospital services. The 2014 update covered additional areas such as radiology services, dietitian privileges, and transplant center reporting. The presentation provides an overview of the regulatory changes finalized in these Federal Register entries and notes that the full presentation with more details can be accessed at a given URL.

1. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 1
The Latest Change for the CMS CoPs and New Regulations
Presenter
Duane C. Abbey
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Understanding Hospital CoPs: Standing Orders, Order Sets and
Protocols

2. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 2
Hospital CoPs – 2014 Update
Foreword
 We Will Address:
 Conditions of Participation (CoPs) Update Process
• Federal Register  Proposed and Final
 May 16, 2012 – (Part I)
 May 12, 2014 – Part II
• FR Modifies the Code of Federal Regulations
• Later, the State Operations Manual is Updated
 See Appendix A for Hospitals
 Generally Through Transmittals
 Hospital CoPs – Conditions of Participation
• Found in the CFR – Code of Federal Regulations
• Generally at 42 CFR §482
 CAHs – 42 CFR §485.600 – Subpart F
 Note That There Are Other Types of Changes
• Definitions
• Conditions for Payment

3. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 3
Hospital CoPs – 2014 Update
Overview
 May 16, 2012 Federal Register Entry – Final Rule – 77 FR 29034
 Effective July 16, 2012
 Laundry List of Topics
 Single governing body for multiple hospitals
 Reporting of Restraint-Related Deaths
 Role of other practitioners on the Medical Staff
 Medical staff leadership
 Nursing care plan
 Administration of medications
 Administration of blood transfusions and intravenous medications
 Orders by other practitioners
 Standing Orders

4. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 4
Hospital CoPs – 2014 Update
Overview
 Laundry List of Topics – May 16, 2012 Federal Register
 Verbal Orders
 Authentication of Orders
 Infection Control Log
 Outpatient Services Director
 Transplant Center Process Requirements
 CAH Provision of Services
 Clarifying Changes
• Pharmaceutical Services
• Infection Control
• CAH Personnel Qualifications
• CAH Surgical Services

5. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 5
Hospital CoPs – 2014 Update
Overview
 Federal Register – May 12, 2014 – Effective July 11, 2014 – 79 FR 27105
 This is Part II of the FR referenced on the previous slides.
 Again, a laundry list of topics generally relating to CoPs.
• Radiology services in ambulatory surgical centers
• Hospital registered dietitian privileges
• Hospital supervision of radiopharmaceutical preparation
• Hospital reclassification of swing- bed services
• Transplant centers reports to CMS
• Transplant center re-approval
• CAH provision of services
• CAH, RHC, and FQHC physician responsibilities
• Clinical Laboratory Improvement Amendments Revisions
• Treatment of proficiency testing samples
• Intentional referral carve-out
• Hospital medical staff
• RHC/FQHC definition of physician

6. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 6
To see the complete presentation check the
below link:
http://www.audioeducator.com/hospitals-and-health-systems/cms-cops-and-
new-regulations.html

7. © 1999-2014 Abbey & Abbey, Consultants, Inc. Slide # 6
To see the complete presentation check the
below link:
http://www.audioeducator.com/hospitals-and-health-systems/cms-cops-and-
new-regulations.html