Recap of 2025 CMS Conditions of Participation and Regulations Changes and Updates For Hospitals and CAHs

2025 was an interesting time for health care providers with Federal and state laws changes, updates to Critical Access Hospital regulations and Acute hospitals interpretative guidelines and survey procedures impacting several areas of Appendix A, respectively. Federal and Appellate court actions on OB emergency care and record requests seemed to change daily. There were also important changes to the Office of Civil Rights (OCR) regulations which have an impact on all hospitals, including Critical Access Hospitals.

This webinar will cover the new Interpretive Guidelines for Acute hospitals on five sections, and newly released regulations for Critical Access Hospitals, some which mirror regulations already present for Acute hospitals. Hospitals that accept Medicare and Medicaid payment must comply with these changes for all patients, regardless of the payment source.

Objectives

At the conclusion of part one, participants should be able to:

• Recall the inclusion of “vulnerable patients” in patient rights section
• Describe the new guidelines for unified and integrated QAPI programs for acute and CAHs
• Discuss the new guidelines for ligature safety in an acute hospital
• Describe the new guidelines and regulations for emergency services to include obstetrical emergencies for Acute and CAHs

Detailed Outline

ACUTE APPENDIX A UPDATES

MOON

• Part of the Conditions of Participation

Patient Rights

• Care in a safe setting
• Death reporting

Quality Assessment Performance Improvement Program

• New Interpretive Guidelines for Unified and Integrated programs
• Obstetrical Services and four requirements

Assessment v. Comprehensive History and Physical

• Medical staff
• Medical records
• Surgery section

Nursing Services

• Requirement for RN in outpatient services

Physical Environment

• Ligature risks
• Emergency power and lighting
• Life Safety Code updates
• Maintenance of alcohol-based hand rubs
• Monitoring when sprinkler systems are down
• Windows and therapeutic/diagnostic facilities

Infection Prevention and Control and ASP

• Guidelines updated
• Leadership’s responsibilities

Discharge Planning

• Tag numbers re-numbered and clarified
• Patient evaluation
• Person to develop a plan
• Transfer protocols – new
• PAC services updates

Emergency Services Readiness and Preparedness

• New Tag numbers address readiness, protocols, and training
• Preparedness added when and how exemptions allowed

Obstetrical Services – New Section

• Organization
• Staffing
• Delivery of services
• Training

Psychiatric Hospitals/Units

• New guidelines for all standards
  • Medical records
  • Services
  • Neurological examination
  • Treatment plan
  • Progress notes
  • Discharge summary
  • Staff requirements
  • Nursing, Social, and therapeutic services

CRITICAL ACCESS NEW REGULATIONS

Location and Off-Campus

• 2-lane roads

Patient Rights

• Notice of rights
• Grievances
• Exercise of Rights
• Privacy and confidentiality
• Restraint or seclusion
• Staff training requirements
• Death reporting
• Visitation

Emergency Services

• Provisions and protocols
• Staff training
• Transfer protocols

Physical Plan and Emergency Preparedness

• Life safety code additions
• Training/testing exemptions for emergency preparedness
• Unified and integrated programs

Provision of Services

• Medical Staff – unified and integrated programs
• Interoperability of clinical records
• Antibiotic Stewardship
  • Person qualified
  • Reporting illnesses
  • Unified and integrated programs

Quality Assessment Performance Improvement

• New OB and QAPI requirements
• Unified and integrated programs

Swing Beds

• Cross reference to SNF manual on Patient rights omitted

Obstetrical Services – New Section

• Organization
• Staffing
• Delivery of services
• Training

Resources

Who Should Attend?

• CEOs
• COOs
• CMO
• CNO
• Emergency department manager and physicians
• Compliance director
• Nurse managers/supervisors
• Quality managers
• Risk managers
• Health information management personnel
• Nurses
• Nurse educators
• Surgical supervisor and physicians
• Patient safety officer
• Infection preventionist
• Infection control team members
• Leader of Antibiotic Stewardship program
• QAPI leaders and staff