Nursing: CMS Conditions of Participation Standards for Hospitals
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Credit Offered
2 HLT Credits
This is a recording of a live webinar delivered on Feb. 27, 2024.

This session covers the nursing services section from the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) manual. Many changes made to the hospital nursing chapter of the CoPs manual are still awaiting interpretive guidelines and survey procedures.

The program discusses often-cited areas of the CoPs manual regarding nursing care, including plans of care, staffing, policy changes, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services has been cited over 8,900 times, according to the most recent report.

Other past changes 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 also references the ever-changing non-discrimination regulations of Section 1557 and briefly covers other sections of the manual that impact nursing.
Laura A. Dixon, BS, JD, RN, CPHRM
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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, 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, 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 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.
At the conclusion of this session, participants should be able to:
  • Explain that CMS has a section on nursing services that every hospital must follow.
  • Recite the three timeframes during which all medications must be administered.
  • Recall that nursing care plans are a frequently cited area by CMS.
  • Discuss the requirements for verbal orders.
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 2 contact hours.

By completing the course, Nursing: CMS CoPs Standards for Hospitals offered by Georgia Hospital Association, participants may earn up to 2 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.

Please complete the course evaluation to earn your certificate of participation.
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