Marketing and Empathy Psychology
CMS CoP Nursing Guidelines: What Every Hospital Nurse Needs to Know

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

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Hospitals that accept Medicare and Medicaid reimbursements must adhere to the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs), applicable to all patients. This webinar will focus on the nursing services section of the hospital CoP manual. Hospitals with Deemed Status accreditation from the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also comply with these regulations.

Significant changes were made to the hospital nursing chapter of the CoPs in 2020, with many changes still awaiting interpretive guidelines and survey procedures.

This session will explore frequently cited areas of the CoP manual regarding nursing care: plans of care, staffing, policy changes, RN requirements in outpatient departments, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services have been cited over 7,200 times according to the latest report.

Past changes to the Nursing section include medication timing, standing orders, care plans, verbal orders, blood transfusions, IV medications, self-administration of medications, and drug orders. This webinar will also cover other crucial sections nurses should be aware of, such as revised discharge planning standards, history and physicals, visitation, restraint and seclusion, grievances, Section 1557, and non-discrimination.


  • Understand CMS’s nursing services section requirements for hospitals, even if accredited.
  • Identify the three different timeframes for administering medications.
  • Recognize that nursing care plans are a commonly cited area by CMS.
  • Understand the requirements for verbal orders.

Detailed Agenda

  • Introduction to the CMS hospital CoPs manual
  • CMS deficiency reports
  • 2020 changes to Nursing section
  • CMS memos of interest impacting nursing:
  • Insulin pens
  • Infection control breaches
  • Texting of orders
  • Ligature risks
  • Safe injection practices
  • OR humidity requirements
  • Conditions of Participation – Nursing:
  • 24-hour services and RN duties
  • Organizational chart and nursing roles
  • Chief Nursing Officer (CNO) responsibilities
  • Staffing and care delivery
  • Nursing care plans and updates
  • Agency nurse requirements
  • Medication administration protocols
  • Order requirements for medications
  • Timing changes for medications
  • Safe opioid use
  • Verbal orders
  • Blood transfusions and IV medication updates
  • Reporting medication errors
  • Self-administered medications
  • CAH Nursing requirements
  • Other Manual sections important for nursing:
  • Restraint and seclusion
  • Medication policies
  • Visitation
  • Revised discharge planning standards
  • Additional Information impacting nursing:
  • CDC resources on preventing healthcare-acquired infections (HAI)
  • ISMP safe injection practices
  • Non-discrimination, interpreters, and Section 1557
  • Appendix and Resources

Who Should Attend?

  • Chief nursing officers
  • Nurses of all levels
  • Nurse managers/supervisors
  • Nurse educators
  • Compliance officers
  • Chief of medical staff
  • Risk managers
  • Patient safety officers
  • Senior leadership
  • Joint Commission coordinators
  • Regulatory officers
  • Physicians
  • Audit staff

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Speaker Detail

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

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. 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 medical malpractice insurance 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.

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