Nursing CMS CoP Standards for Hospitals 2022

Date : March 10, 2022
Time: 01:00 PM ET
Duration: 120 Minutes
Speaker : Laura A. Dixon



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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, 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.

Other 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.

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.

This program will also reference other important sections that all nurses should be aware that are outside the nursing services section.  Such sections include 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.


Detailed Agenda

  • 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
  • Final changes under the Hospital Improvement Rule to nursing
  • CMS 3 Worksheets
  • CDC resources on preventing healthcare acquired infections (HAI)
  • CMS memos of interest
    • Infection control breaches
    • Texting
    • Ligature risks
    • Legionnaire’s
    • Safe injection practices
    • Humidity in the OR
  • ISMP safe injection practices
  • Non-Discrimination, Interpreters, and section 1557
  • Nursing Services and 24 hours services
  • RN on duty – recent update
  • 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
  • RN to evaluate to care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • Medication administration
  • Order required for all medications
  • BUD, compounding sterile preparations (CSP)
  • Protocols, standing orders, order sets
  • Requirements for complete drug order
  • Compounding of medications
  • Three medications timing changes
  • Safe Opioid use
  • Standing orders and protocols
  • Verbal orders
  • Blood transfusions and IV medications changes
  • Reporting blood administration and medication errors
  • Self-administered medications
  • CAH Nursing requirements
  • 1135 Waivers for sections addressed
    • Care-at-home


Other important sections nurses should be aware of:

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


Appendix and resources


  • Recall that CMS has a section on nursing services that every hospital must follow even if accredited
  • Describe the three different timeframes for which all medications must be administered
  • Discuss that nursing care plans are a frequently cited area by CMS
  • Recall that verbal orders must be signed off and must include both a date and time


Who Should Attend?

  • Chief nursing officer
  • All nurses
  • Nurse managers/supervisors
  • Nurse educators
  • HIM Director and staff
  • Compliance officer
  • Chief of medical staff
  • Medical staff coordinator
  • Risk manager
  • Patient safety officer
  • Senior leadership
  • Hospital legal counsel
  • QAPI director
  • Joint Commission coordinator
  • Regulatory officers
  • Physicians
  • Education department staff
  • Board members
  • Audit staff
  • Others responsible for compliance with hospital nursing regulations including documentation compliance.


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.