Home Events CMS Pharmacy and Medication: Complying with the Hospital CoPs

CMS Pharmacy and Medication: Complying with the Hospital CoPs

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 10/18/2022

9:00 – 11:00 AM Central time


Registration fees:       $225 per NDHA member  |  $275 per non-member


Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


Medication errors are the most common medical errors in health care and are the most frequent cause of unnecessary readmissions to the hospital. According to the Centers for Medicare & Medicaid Services (CMS), drug-related adverse outcomes occur in 1.9 million inpatient stays or almost 5% of all admissions. There are also 838,000 patients a year who are treated as outpatients who have a drug-related adverse event. If a surveyor showed up at your hospital today, would you be prepared? Are you up to speed with the new antibiotic stewardship requirements and pharmacy’s involvement in the new regulations under the Hospital Improvement Rule which became final on November 29, 2019? CMS also made changes to three of the 18 pharmacy tag numbers in 2020; however, interpretive guidelines and survey procedures are still pending. There have also been changes to the nursing section that addresses medication usage. For the first time, CMS states that nursing needs to be aware of the pharmacy standards and vice versa. This includes changes to timing of medication, self-administered medication, compounding, safe opioid use and required medication policies. This program will review the most problematic pharmacy and medication standards and provide guidance and resources to ensure that your facility or system stays in compliance.


At the conclusion of this session, participants should be able to:

  • Recall that all hospitals that receive Medicare/Medicaid reimbursement must follow the medication guidelines for all patients.
  • Discuss that CMS has requirements on beyond use date (BUD) and compounding.
  • Recite that CMS has several required pharmacy policies and procedures.
  • Describe that CMS requires a policy for high-risk drugs such as double checks or dose limits.



Darlene Evans is a health care quality leader with more than 25 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and business development. She has a proven track record of helping clients identify opportunities for improvement to achieve sustainable, long-term results. She has also helped lead organizations through operational effectiveness, infrastructure, staffing and productivity, fiscal stewardship, leadership development, and care delivery. Previously, Darlene worked with the Joint Commission International as a hospital and ambulatory care accreditation surveyor for health care organizations in Turkey, India, Ireland, Saudi Arabia, UAE, and China. In addition to her consulting and surveyor experience, she has served in leadership roles including chief nursing officer, vice president of patient care services, assistant vice president of nursing services, and director of quality management and education. Darlene earned her master’s and bachelor’s degrees in nursing from Troy State University in Troy, AL. She is Lean Six Sigma certified and is a registered nurse, a certified Professional in Healthcare Quality, and a member of the American College of Healthcare Executives and the National Association for Healthcare Quality.


This speaker has no real or perceived conflicts of interest that relate to this presentation.


Oct 18 2022


9:00 am - 11:00 am

More Info

Register Here
Register Here
No Comments

Post A Comment