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CMS Hospital Surgery, Anesthesia, and PACU, CoP Requirements; Are You in Compliance?

Recorded Session | Sue Dill Calloway | From: Sep 14, 2020 - To: Dec 31, 2020
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Course Description

This program will cover the CMS hospital CoP standards for surgery, anesthesia, and PACU. Every hospital that accepts Medicare and Medicaid must follow these standards and they must be followed for all patients. This program will cover some of the important CMS memos that discuss medication management, IV, and safe opioid use. This will cover the changes to H&P that went into effect on November 29, 2019, and February 21, 2020, and the interpretive guidelines will be published in 2020. Hospitals can elect to do an assessment on healthy outpatients undergoing surgery or a procedure instead of an H&P.

CMS recently issued a deficiency report. This program will go over the number of deficiencies and types received by hospitals from CMS. This has many important issues such as informed consent, H&Ps, safe opioid use, safe injection practices, compounding, and beyond use dates (BUDs). The BUD date was supposed to be changed on December 1, 2019, but was delayed to 2020.

Do you have all the required policies required by CMS? This program will discuss the many standards required by the surgery department and anesthesia. Hospitals will need to make sure their policies and procedures reflect these requirements.

Are you confused as to what the final anesthesia standards are after four revisions? CMS made four revisions over a two year period and no further changes are anticipated. The speaker has authored a book on the CMS anesthesia standards.

How do these standards affect sedation done in the emergency department and GI lab? Come to this program and learn the current CMS guidelines. This includes the current interpretive guidelines regarding pre-anesthesia evaluations, post-anesthesia evaluation, and anesthesia services. Hospitals are required to have many policies including one on specific clinic situations involving anesthesia or analgesia. This includes interpretive guidelines on moderate sedation and deep sedation. It impacts moderate and deep sedation done in other places like the emergency department and GI lab and patients who have ECTs.

The history and physical and informed consent form must be on the chart before surgery except in an emergency. An exception is made for young healthy outpatients if hospitals implement policies and follow the requirements.

A study found that 66% of the time the consent was missing which resulted in a delay of 10% of surgical procedure. This cost the average hospital almost $600,000 a year. What surgical equipment is required? Come learn the answers to these questions and many more.


  • Recall that there are a number of policies and procedures required by CMS related to surgery and anesthesia services
  • Describe that CMS has a section that addresses PACU requirements
  • Recall that CMS has a list of things that must be included in the OR register
  • Describe what information is required for informed consent and that it should be on the chart before surgery
  • Discuss the 48-hour requirements for the post-anesthesia evaluation of both inpatients and outpatients.


Surgery and PACU

  • CMS deficiency report
  • CMS current manual and new website
  • 2020 changes
  • CMS Certification and Survey Memos
    • Humidity in the OR
    • Safe injection practices
    • Infection control breaches memo
    • CMS worksheets with a section on safe injection practices
  • What constitutes surgery?
  • Infection control in ORs
  • Equipment, temperature, humidity
  • Supervision in the OR
  • Scrub tech and circulators
  • Surgical privileges
  • Surgery policies required
  • Preventing OR fires
  • History and physical and November 29, 2019, and 2020 changes  
  • Informed consent
  • OR register
  • PACU standards
  • Operative report requirements
  • Surgery equipment required
  • PACU standards
    • Monitoring of patients receiving opioids


  • Must comply if the hospital does any type of anesthesia
  • Director of Anesthesia Services
  • Anesthesia versus analgesia
  • General, regional, MAC, topical, minimal sedation, moderate sedation
  • Rescue capacity
  • OR, Radiology, ED, Clinics, Psychiatry and other sites where anesthesia is   provided
  • QAPI
  • Director of Anesthesia responsibilities
  • Who can administer anesthesia
  • Scope of practice for CRNA and Anesthesia Assistants
  • CRNA state exemption
  • Anesthesia Policies required
  • Criteria for privileges
  • Pre-anesthesia assessment
  • Post-anesthesia evaluations
  • Consent, infection control, documentation, safety policies required
  • Documentation requirements
  • Intraoperative anesthesia record requirements

Who Should Attend?

  • Director of the OR and OR nurses/staff
  • PACU Nurse Manager/PACU nurses
  • Chief of Anesthesia
  • Anesthesiologist
  • CRNAs
  • Anesthesia Assistants
  • Medical Credentialing Staff
  • Patient Safety Officer
  • Risk Manager
  • Nurses especially in OR and PACU
  • Chief Nursing Officer (CNO)
  • Chief Medical Officer (CMO)
  • Chief Operating Officer (COO)
  • Chief Executive Officer (CEO)
  • OB Nurses and Nurse Director
  • Joint Commission liaison
  • Quality Improvement Director
  • Regulation and Accreditation Director
  • Nurse Educator
  • PI Director
  • Compliance Officer