Hospital Conditions of Participation – Part 5

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This five-part online seminar series will cover the entire CMS Hospital CoP manual – Appendix A. It is a fantastic way to educate everyone in your hospital on all the sections of the CMS hospital manual, especially ones that apply to their department. This program will discuss the most problematic standards and how the hospital can do a gap analysis to assist in compliance with the CoPs.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. The manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital owned departments. Facilities with deemed status accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV Healthcare must follow these regulations.

Sections addressed include infection prevention and control and antibiotic stewardship program, QAPI, medical record services, dietary, utilization review, emergency services, surgical services, anesthesia, PACU, medical staff, nursing services, lab, rehabilitation, radiology, respiratory, physical environment, pharmacy, organ and tissue procurement, patient rights, and discharge planning.

The interpretive guidelines serve as the basis for determining hospital compliance and though some changes from 2020 continue to have interpretive guidelines and survey procedures pending, hospitals are still expected to comply with the regulations. This program will include the 2020 changes, where some of the gaps continue – absence of interpretive guidelines and survey procedures, and any recent updates.

CMS developed worksheets for assessing compliance with the QAPI, discharge planning standards and infection control. Though no longer utilized by State and Federal surveyors, the worksheets are available as excellent self-assessment tools for hospitals. These three worksheets will be covered.

Registration Pricing

Member: $175 per webinar
Non-Member: $225 per webinar
Registration includes unlimited connections per registered facility.

Register via PDF

Who Should Attend:

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.

Continuing Education

Continuing Medical Education
This educational activity is jointly provided by AXIS Medical Education and Texas Hospital Association.
The Texas Hospital Association is applying for approval from the following accrediting organizations for the CMS Hospital Conditions of Participation (CoPs) 2024 Webinar Series.

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 2.0 contact hours each.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

Credit Designation for Physicians
AXIS Medical Education designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™ each. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Click here for more continuing medical education information.

American College of Healthcare Executives
By attending the Hospital Conditions of Participation (CoPs) Webinar Series offered by Texas Hospital Association participants may earn up to 2.0 ACHE Qualified Education Hours each toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

Learning Objectives:

  • Discuss that CMS requires many policies in infection prevention and control
  • Recall that patients referred a post-acute care provider – PAC – must be given a list in writing of those available and this must be documented in the medical record
  • Describe that all staff must be trained in the hospital’s policy on organ donation
  • Recall that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment

Faculty

Laura A. Dixon, BS, JD, RN, CPHRM, President, Healthcare Risk Education and Consulting, LLC, Denver, CO

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’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

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.