CMS Hospital Conditions of Participation (CoPs) 2021: Nursing Standard Section

Date : September 21, 2021
Time: 01:00 PM ET
Duration: 90 Minutes
Speaker : Laura A. Dixon





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.

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.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, protocols, standing 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.

CMS made previous revisions to IV medication administration, blood transfusion, safe injection practices, compounding, beyond use date (BUD)and implemented safe opioid standards. Hospitals continue to struggle with how to comply with these complicated standards, especially the safe opioid interpretive guidelines.

There are many changes in the past to this section include timing of medications, standing orders, soft wrist restraints and restraint reporting, plan of care, verbal orders, blood transfusions, IV medication, compounding, BUD, antibiotic stewardship program, safe injection practices, self-administration of medications and drug orders.

CMS also issued the final worksheets on QAPI, discharge planning and infection control which should be on the radar screen of all department managers especially because there were changes in 2020 in all these sections and with interpretive guidelines and survey procedure still to be decided by CMS. There are also proposed changes to the infection control worksheet which will be discussed.

This program will also cover other important sections outside the nursing section that all nurses should be aware of including: 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, relative humidity memo, and insulin pen memo.

The nursing 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. CMS deficiency reports will be covered so hospitals are aware of which are the problematic tag numbers.


Detailed Agenda

  • Introduction into the CMS hospital CoPs
  • CMS deficiency reports and problematic standards
  • How to keep apprised of changes
  • Changes to medication management, IV, blood, and opioid safe use
  • ISMP IV push guidelines
  • Safe injection practices
  • Changes related to safe injection practices, compounding, medication preparation, immediate use, and labeling
  • CMS Hospital work sheets and importance
  • Recent CMS memos of interest
  • Reporting requirements under COVID-19 pandemic
  • CDC resources on preventing HAI
  • Nursing Services and 24 hours services
  • RN on duty
  • Integrated with hospital wide PI program
  • Chief Nursing Officer (CNO) responsibilities
  • 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
  • Order required for all medications
  • OCR Section 1557 and 2021 changes
  • Standards of care and practice to prevent HAI
  • BUD, compounding sterile preparations (CSP)
  • Safe injection practices
  • Standing orders and protocols
  • Three medicationstiming 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


Other important sections nurses should be aware of:

  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation
  • History and physicals
  • Discharge planning revised standards



  • Identify the CMS section on nursing services that every hospital must follow even if accredited
  • Describe that all medications must be administered within three different time frames
  • Discuss that nursing care plans are a frequently cited area by CMS
  • Discuss that all verbal orders must be signed off and need to include both a date and time
  • Identify the focus on safe injection practices by CMS


Who Should Attend?

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 operating officer, chief medical officer, physicians, education department staff, board members, director of health information management,  audit staff, and others responsible for compliance with hospital nursing regulations including documentation compliance.

NOTE:  CMS has a separate CoP for critical access hospitals (CAHs). However, since the CAH nursing CoPs were rewritten on April 7, 2015 and in 2020, they are for the most part the same or a shorten version. These differences are discussed. Any CAH attending can have access to the CAH nursing CoPs because the tag numbers are different. All the CAH tag numbers changes in 2020.


Laura A. Dixon

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 representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice 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.