This webinar covers the hospital Conditions of Participation (CoPs) that affect the emergency department and overall emergency services within a facility. Interpretive guidelines are in two separate sections of the hospital CoP manual – Appendix A for Acute hospitals starting at Tags A91 – 94 and then Tags A1100 – 1112. Regulations and guidelines are in one section of Appendix C for Critical Access Hospitals, beginning at Tags C 880 - C898.  EMTALA is in a separate section – Appendix V.

Any hospital that accepts Medicare must follow the CMS CoPs and all patients. This program will cover the initial section of the manual that discusses staffing requirements, provision of services both on and off-campus, required policies and procedures, training requirements, medical director requirements, and compliance with standards of care. EMTALA will be addressed briefly; EMTALA is a separate multiple webinar program. This program will also cover recent changes to the overall many that impact emergency services including requirements for restraint and seclusion, grievances, and protocols.

This program will provide education as to what hospital emergency departments need to do to prevent being out of compliance with the CMS hospital requirements.

• Recall that CMS has a section in the hospital CoP manual on emergency services
• Discuss that CMS requires the emergency department to have specified policies and procedures
• Describe that there are restraint and seclusion standards that staff must follow
• Explain what has required if the patient files a grievance

• Introduction
• Location of the manual
• Survey memos
• Access to survey deficiency data
• EMTALA and 2019 changes
• Provision of emergency services
• Required Policies
• Hospitals without emergency departments
• Adequacy of staff and staff training
• Transport policies
• On-campus and off-campus responsibilities
• Medical Staff and emergency procedures
• Meeting needs of patients
• Following standards of care (a) ACEP and ENA
• QAPI
• Lab, x-ray, medical records, surgery responsibilities
• A qualified medical director required
• Direction and supervision of department and staff
• Urgent care services
• Equipment and supplies
• Staffing
• Critical Access Hospitals emergency services
• Director and policies and procedures
• Staff numbers and qualifications 
• Blood, blood products, and laboratory 
• EMTALA overview
  • Lists and logs
  • Medical screening examination
  • Stabilizing treatment
  • No delay in transfer
  • Requirements for receiving hospital
• 2019 changes that impact emergency services
  • Restraint and seclusion
  • Grievance
  • Protocols and standing orders
  • Interpreters
  • Safe injection practices

• CEOs
• COOs
• CFOs
• Nurse Executives (CNO)
• Accreditation and Regulation Director
• Nurse Managers
• Pharmacists
• Pharmacist Compliance Officers
• Health information management
• Nurses
• Nurse Educators
• Nursing Supervisors
• Quality Managers
• Patient safety officer
• Infection preventionist
• Radiology director
• Emergency Department Directors
• Outpatient Director
• Medication Team
• Ethicist
• Director of Rehab: OT, PT, speech pathology, and audiology
• CRNA
• Anesthesia providers
• Radiology staff
• QAPI staff
• Policy and Procedure Committee
• Risk Managers
• Healthcare Attorneys
• Infection Control Committee Members