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Nursing: CMS CoP Standards for Hospitals

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

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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.
There were some changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020. However, many of those changes are still awaiting interpretive guidelines and survey procedures.

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, and more. Nursing services has been cited over 7,200 times according to the most recent report.

Other changes in the past 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 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, revised history and physicals, visitation, restraint and seclusion and grievances, and Section 1557 and non-discrimination.


  • 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 the requirements for verbal orders
  • Detailed Agenda
  • Introduction into the CMS hospital CoPs manual
  • CMS deficiency reports
  • 2020 changes to Nursing section
  • CMS memos of interest that impact nursing
    • Insulin pens
    • Infection control breaches
    • Texting of orders
    • Ligature risks
    • Safe injection practices
    • Humidity in the OR
  • Conditions of Participation – Nursing
  • Nursing Services and 24 hours services
  • RN on duty – recent update
  • Organizational chart and nursing
  • Chief Nursing Officer (CNO) responsibilities & requirements
  • 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
  • Protocols, standing orders, order sets
  • Requirements for complete drug order
  • 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

Other Manual sections of importance to nursing

  • Restraint and seclusion
  • Medication policies
  • Visitation
  • Discharge planning revised standards

Additional Information that Impacts 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 officer
  • All nurses
  • Nurse managers/supervisors
  • Nurse educators
  • Compliance officer
  • Chief of medical staff
  • Risk manager
  • Patient safety officer
  • Senior leadership
  • Joint Commission coordinator
  • 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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