Home Events Medical Staff and Telemedicine: Meeting CMS CoPs and TJC Standards

Medical Staff and Telemedicine: Meeting CMS CoPs and TJC Standards

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

Date: 9/13/22

9:00 AM – 11:00 AM Central time


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


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


There are over 800 deficiencies from the Centers for Medicare & Medicaid Services (CMS) related to the medical staff section of CMS Conditions of Participation (CoPs) manual. A significant change to the CoPs under the Transparency Rule includes revisions to the history and physicals for healthy patients having outpatient procedures. Additionally, updates were made to autopsy rules and will be discussed in this webinar. CMS allows a hospital system to share a medical staff, which CMS refers to as a unified and integrated medical staff. The board and medical staff sections will be reviewed in detail through this webinar. There will also be a concurrent discussion of The Joint Commission (TJC) standards for a medical staff. Although telemedicine has been a factor in health care for many years, COVID-19 gave it a larger role in diagnosis and treatment of patients. With the expanded use, the federal government, some states, and health insurers, quickly suspended regulations that limited telemedicine. Telemedicine continues to be a significant factor in health care today. Every hospital and critical access hospital performing telemedicine should ensure compliance. Standards for both will be discussed.


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

  • Recall that hospitals can have a separate medical staff or a unified shared integrated medical staff.
  • Describe the requirements for a medical staff under CMS Conditions of Participation and TJC standards.
  • Discuss the requirement that hospitals must have a written agreement that specifies the responsibilities of the distant-site hospital and entities to meet the required credentialing requirements.
  • Recall that Joint Commission has standards on telemedicine.



Lena Browning is a nurse leader and accreditation specialist with more than 25 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 three interim positions as director of accreditation and was responsible for restructuring accreditation departments and leading organizations in compliance. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy (IJ) situations with all organizations getting the IJ lifted and no condition level findings noted on return surveys. Prior to consulting, Lena had over two 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 continuous readiness committees, and coached staff and leadership in compliance and performance improvement strategies. Lena earned a Master of Healthcare Administration from the University of Southern Indiana and a Bachelor of Science in Nursing from Murray State University. She 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).



Sep 13 2022


9:00 am - 11:00 am

More Info

Register Here
Register Here
No Comments

Post A Comment