OasisLMS

Part One: Thursday, Jan. 15 (10 a.m.-noon ET) 

Part Two: Thursday, Jan. 22 (10 a.m.-noon ET) 

Part Three: Thursday, Jan. 29 (10 a.m.-noon ET) 

Part Four: Thursday, Feb. 5 (10 a.m.-noon ET) 

Part Five: Thursday, Feb. 12 (10 a.m.-noon ET) 

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director of facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.

Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Dixon 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.

This speaker has no real or perceived conflicts of interest that relate to this presentation.

This five-part webinar series will cover the major sections of the Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation (CoPs) manual, Appendix A.

Every hospital that accepts payment from Medicare and Medicaid must comply with the CMS CoPs. Facilities with deemed status accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV Healthcare must also follow these regulations.

The series will address infection prevention and control and antibiotic stewardship, 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.

At the conclusion of this series, participants should be able to:

Part One:

• • Explain how to locate a copy of the current CMS CoPs manual.
  • Describe the time limitations for a history and physical for an inpatient undergoing elective surgery.
  • Discuss that a physician must sign off on verbal orders and provide a date and time.
  • Recall the four exceptions to information blocking.

Part Two:

• Recall that CMS has restraint standards that hospitals must follow.
• Describe that a hospital must have a grievance policy and procedure in place.
• Discuss that interpreters should be provided for patients with limited English proficiency and hearing impairment.
• Describe how non-physician practitioners – PA, NPs – can order restraints.

Part Three:

• Describe which medications must be given timely and within one of three blocks of time.
• Explain that all orders/protocols should be approved by the medical staff and an order entered into the medical record and signed off.
• Recall that a nursing care plan must be in writing, started soon after admission, and maintained in the medical record.
• Describe patient safety issues with compounding pharmacies.
• Discuss that the hospital must have a safe opioid policy approved by the MEC, and staff must be educated on the policy.

Part Four:

• Recall the requirements for and elements of a QAPI program.
• Describe the need for radiology policies, including radiation safety and need for qualified staff.
• Discuss the new option of credentialing the dietician to order diets, if allowed by the state.
• Describe the need for facility maintenance program to include water management.

Part Five:

• Discuss that CMS requires many policies in infection prevention and control.
• Recall that patients referred to 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 the post-anesthesia assessment items that CMS requires to be documented in the medical record.
• Explain the new Condition of Participation for obstetrical services, including required staff training, equipment and provisions, equipment and organization.

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a).  Approved for 10 contact hours. 

By attending Acute Care Hospital Conditions of Participation, Five-Part Webinar Series offered by Georgia Hospital Association, participants may earn up to 10 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.

If you need assistance with registration, please contact the education department at education@gha.org or 770-249-4529.