Nursing: CMS CoP Standards for Hospitals (W6005)-Nursing: CMS CoP Standards for Hospitals Presentation

Nursing: CMS CoP Standards for Hospitals Presentation

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The document is a webinar-style overview of 2026 CMS Conditions of Participation (CoPs) and related guidance affecting nursing in acute care hospitals and Critical Access Hospitals (CAHs). It highlights common CMS survey deficiencies (e.g., failure to supervise nursing care, follow orders, monitor restraints, secure medications, investigate abuse allegations, implement fall precautions, and maintain/updating care plans).<br /><br />Major CMS memos emphasized include the July 2023 ligature risk guidance (no waivers; monthly progress reporting if cited) focusing on three compliance elements: (1) behavioral health patient risk assessment, (2) staffing/monitoring with required training for all staff initially and at least every two years, and (3) unit-specific environmental risk assessments. A June 2023 discharge planning memo reiterates that discharge planning must be effective, centered on patient goals/preferences, and include patients and caregivers; hospitals must send complete, accurate information to post-acute care (PAC) providers, with key risk areas such as medications, durable medical equipment, skin issues, communication of home needs, behavioral health/SUD complexity, and goals of care.<br /><br />Section 1557 nondiscrimination and language access requirements are summarized: post required notices/taglines (multiple languages), provide qualified interpreters and aids at no charge, train staff, and designate a grievance/complaint handler; surveyors may refer observed issues to OCR.<br /><br />For acute hospitals, nursing CoPs covered include: an organized nursing service with 24/7 RN availability; a qualified RN CNO overseeing staffing and policies; ensuring “immediate availability” of an RN on each unit; license verification (including OIG exclusion checks); RN supervision/evaluation for every patient; and maintaining a current nursing care plan integrated with interdisciplinary planning. Guidance addresses agency nurse oversight, outpatient areas where an RN is not physically present (criteria and alternative staffing plans), and extensive medication administration requirements: medical staff–approved policies, the “rights” of medication administration, safe injection/CSP practices, IV push standards (ISMP), beyond-use dating, updated medication timing windows (time-critical vs non-time-critical), monitoring for adverse effects (especially high-alert meds/opioids), verbal/standing orders controls, blood/IV administration competence, and reporting of reactions/errors into QAPI. CAH standards parallel these themes with specific tags for nursing leadership, staffing, medication policies, and inpatient care plans.

Keywords

2026 CMS Conditions of Participation (CoPs)

CMS nursing survey deficiencies

ligature risk guidance July 2023

behavioral health patient risk assessment

environmental risk assessment behavioral health units

discharge planning requirements June 2023

post-acute care (PAC) transfer communication

Section 1557 nondiscrimination language access

medication administration rights and IV push standards

Critical Access Hospital (CAH) nursing CoPs and staffing