CMS Conditions of Participation

Pharmacy Conditions of Participation

Jan. 23, 2024, 12 - 1:30 p.m.


This session will provide information about the recent changes in Medicare’s conditions of participation, which require hospitals to establish a formalized antibiotic stewardship program. This program also reviews the existing conditions of participation and problematic pharmacy standards. The CMS interpretive guidelines address medication management and pharmacy-related standards. Hospitals can look to these standards when CMS conducts a survey. Medication management also is a focus for The Joint Commission. Medication errors account for the largest number of medical errors in health care. They are also the most- common reason for unnecessary hospital readmissions. For the first time, CMS mentions that nursing needs to be aware of the pharmacy standards. This includes medication errors, adverse events, drug incompatibilities, self‐administered medication and required medication policies.

Learning objectives

  • Describe CMS requirements for pharmaceutical services.
  • Explain basic required policies and procedure
  • Describe minimum security requirements.
  • Explain pharmacist role in antibiotic stewardship and medication error prevention.

Recommended to attend

This program is intended for all hospitals and health systems including general acute hospitals, critical access hospitals, and anyone involved with compliance regulations and standards, including but not limited to pharmacy directors, staff pharmacists, pharmacy technicians chief executive officers, chief medical officers, chief clinical officers, chief nursing officers, quality improvement staff, risk managers, compliance officers and legal counsel, regulatory readiness liaisons, safety officers, department directors, and other interested staff.

Continuing Education

This program has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 1.5 contact hours.

Nursing Home Administrators: The content of this conference is being reviewed by the Board of Examiners for Nursing Home Administrators for clock hours. The quantitative value assigned will be indicated on the certificate of attendance awarded to participants who attend sessions. 


  • $60 for MHA member hospital and health systems
  • $60 for MHA associate members
  • $75 per person for nonmembers 

Registration deadline

Please register by noon on the day before the webinar to ensure timely delivery of access instructions.

If you have any questions, please reach out to

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When and Where
  • 1/23/2024 12:00 PM CST
  • 1/23/2024 1:30 PM CST
  • Zoom Webinar