Nursing:CMS CoP Standards for Hospitals
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Speaker : LAURA A DIXON
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When : Tuesday, June 24, 2025
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Time : 03 : 00 PM EST
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Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she 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.
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 has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.
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.
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 with Deemed Status accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.
There were some changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020. However, many of those changes are still awaiting interpretive guidelines and survey procedures.
This program will discuss the often-cited areas of the CoP manual involving nursing care: plans of care, staffing, policy changes, when a RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services has been cited over8,900times according to the most recent report.
Other changes in the past to the Nursing section include timing of medications, standing orders, plan of care, verbal orders, blood transfusions, IV medication,self-administration of medications and drug orders.
This program will also reference the ever-changing non-discrimination regulations of Section 1557, and briefly mention other sections of the manual that impact Nursing and for which nurses should be aware.
Areas Covered
- Introduction into the CMS hospital CoPs manual
- CMS deficiency reports
- 2020 changes to Nursing section
- Recent memos affecting nursing
- Ligature risks Discharge Planning
- Non-Discrimination and Nursing
- Conditions of Participation - Nursing
- Nursing Services and 24-hour services
- RN on duty – recent update
- Organizational chart and nursing
- Chief Nursing Officer (CNO) responsibilities& requirements
- Staffing and delivery of care24-hour nursing services and supervision
- RN to evaluate to care of all patients
- Nursing care plans
- Changes to the plan of care
- Assignment of patient care
- Agency nurse requirements
- Outpatient departments
- Medication administration
- Order required for all medications
Requirements for complete drug order
- Medication safety and “5 Rights”
- Safe Injection practices
- Three medication stiming changes
- Safe Opioid use
- Standing orders and protocols
- Verbal orders
- Blood transfusions and IV medications changes
- Reporting blood administration and medication errors
- Home and Self-administered medications
- CAH Nursing requirements
- Other manual section of importance to Nursing
- Restraint and seclusion
- Medication policies
- Visitation
- Discharge planning revised standards
- Appendix and Resources
Learning Objectives
- Recall that CMS has a section on nursing services that every hospital must follow even if accredited
- Describe the three different time frames for which all medications must be administered
- Discuss that nursing care plans are a frequently cited area by CMS
- Recall the requirements for verbal orders
Who Should Attend
- Chief nursing officer
- All nurses
- Nurse managers/supervisors
- Nurse educators
- Compliance officer
- Chief of medical staff
- Risk manager
- Patient Safety officer
- Senior leadership
- Joint Commission coordinator
- Regulatory officers
- Physicians
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$200.00
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