2-Hour Virtual Seminar on Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2021 Update

Date: Thursday,
May 20, 2021

10:00 AM PDT | 01:00 PM EDT

2 Hours
Laura A. Dixon
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Live + Recorded
$359 $448  
One Attendee
Live + Recorded
$699 $848  
Unlimited Attendees ?


There were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020 and it is anticipated there will be additional changes in 2021.

In late 2020, CMS made changes to the section in response to COVID-19 pandemic for “hospital at home” facilities. There have been over eighteen CMS survey memos of importance issued relating to nursing in the recent past. The final changes were in the Hospital Improvement Rule.

This program will discuss plans of care, staffing, policy changes, when a RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement and more.

CMS has issued deficiency reports which includes which are the most problematic standards for hospitals. The nursing services has been cited over 6,300 times according to the most recent report. This is a must attend program for any chief nursing officer, clinical nurse or nurse supervisor or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. This must attend program and will discuss the deficiencies and how hospitals can ensure compliance.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV GL Healthcare must also follow these regulations.

This program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as the revised discharge planning standards, medication standards, revised history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, three-time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols.

Why you should Attend: Fear, uncertainty and doubt.

Areas Covered in the Session:

  • Introduction into the CMS hospital CoPs
  • General information on CMS including online access and email contact for CMS to ask questions
  • CMS deficiency reports and problematic standards
  • Changes to medication management, IV, blood, and opioid safe use
  • Final changes under the Hospital Improvement Rule to nursing
  • ISMP IV push guidelines
  • Safe injection practices
  • Changes related to safe injection practices, compounding, medication preparation, immediate use, and medication labeling
  • CMS Hospital work sheets and importance
  • Recent CMS memos of interest
    • Hospital deficiencies
    • Safe injection practices
    • Legionnaire's
    • Reporting to the PI system
    • Insulin pens and safe injection practices
    • Organ Procurement Organization Contracts
    • Discharge planning standards
    • CMS complaint manual
    • Humidity in the OR
  • CDC resources on preventing healthcare acquired infections (HAI)
  • Nursing Services and 24 hours services
  • RN on duty – recent update
  • Integrated with hospital wide PI program
  • Organizational chart and nursing
  • Chief Nursing Officer (CNO) responsibilities & requirements
  • CNO approval of nursing policies
  • Staffing and delivery of care
  • 24-hour nursing services and supervision
  • Valid license for nurses and verification
  • RN to evaluate to care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • Orientation of agency nurses
  • Medication administration
  • Order required for all medications
  • OCR Section 1557 and 2020 changes
  • Standards of care and practice to prevent HAI
  • BUD, compounding sterile preparations (CSP)
    • Immediate use
    • Administration one hour rule
  • Safe injection practices
  • Standing orders and protocols
  • Three medications timing changes
  • Protocols, standing orders, order sets
  • Requirements for complete drug order
  • Verbal orders
  • Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self-administered medications
  • 1135 Waivers for sections addressed

Other important sections nurses should be aware of:
  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation
  • History and physicals
  • Discharge planning revised standards

Who Will Benefit:
  • Chief Nursing Officer
  • All Nurses
  • Nurse Managers
  • Nurse Supervisors
  • Nurse Educators
  • HIM Staff
  • Compliance Officer
  • Chief of Medical Staff
  • Medical Staff Coordinator
  • Risk Manager
  • Patient Safety Officer
  • Senior Leadership
  • COO
  • Documentation Specialist
  • Hospital Legal Counsel
  • QAPI Director
  • Joint Commission coordinator
  • Regulatory Officers
  • Legal Counsel
  • Chief Medical Officer
  • Physicians
  • Education Department Staff
  • Board Members
  • Director of Health information Management
  • Audit Staff
  • Others Responsible for compliance with hospital nursing regulations including Documentation Compliance

Speaker Profile
Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

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