Home Events History and Physicals: Meeting Hospital CoPs in 2022

History and Physicals: Meeting Hospital CoPs in 2022

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

Date: 4/28/22

9:00 – 11:00 AM Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member

Target Audience

CMO, CNO, Compliance Officer, Emergency Department personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


The Centers for Medicare & Medicaid services (CMS) made a change effective Nov. 29, 2019 indicating that healthy outpatients may not be required to have a history and physical (H&P). This webinar will outline policy, medical staff and board approval, revised medical staff bylaws, and more. Attendees will learn what is required to be in the H&Ps and how to comply with both the CMS hospital conditions of participation and with the Joint Commission standards. CMS has five separate tag numbers and has also issued a deficiency memo. Information will be presented on how many hospitals received deficiencies in these areas of discussion. This presentation will also include the standards for critical access hospitals.

The Joint Commission has many frequently asked questions on H&Ps that will be discussed including delegation of H&P, H&P for outpatient procedures, medical students doing H&Ps, podiatrist or dentist doing H&P, prenatal assessment, updated requirements of the H&P and authentication of H&Ps.

Learning Objectives:

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

  • Recall that CMS has five H&P requirements in the hospital conditions of participation that all hospitals that accept Medicare must follow.
  • Recite the Joint Commission standards on H&P.
  • Identify that CMS issued clarification changes for hospitals on H&Ps in a CMS survey and certification memo
  • Describe that the hospital must have medical staff by-laws and policies that include the requirements for H&Ps
  • Discuss what hospitals must do to implement the new rule that H&Ps do not need to be done on healthy outpatients



Lena Browning, MHA, BSN, RNC-NIC, CSHA
Nash Healthcare Consulting

Lena Browning is a nurse leader and accreditation specialist with more than twenty-five years of experience in clinical leadership in acute care settings. As a Principal Consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled 3 Interim positions as Director of Accreditation and was responsible for restructuring accreditation departments and leading organizations in continuous compliance and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy situations with all organizations getting the IJ lifted, and no condition level findings noted on return surveys. Prior to consulting, Lena had over 2 decades of experience in Accreditation and Regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired, and facilitated continuous readiness committees, and coached staff and leadership in effective compliance and performance  improvement strategies. Additionally, Lena has extensive experience in Quality and Patient Safety, Performance Improvement, Medical Staff Credentialing and Privileging, Contract Management, and Strategic Planning for Hospitals and Home Care Agencies. Lena earned her Master of Healthcare Administration from the University of Southern Indiana and her Bachelor of Science in Nursing from Murray State University. She is a Registered Nurse Certified in Neonatal Intensive Care, a Certified Specialist in Healthcare Accreditation, and holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post resuscitation stabilization. She is also a member of the Association for Professionals in Infection Control and Epidemiology (APIC).

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


Apr 28 2022


9:00 am - 11:00 am

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