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.

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.

Part Three of Five: Nursing and Pharmacy

Objectives - At the conclusion of part three, participants should be able to:

• Describe which medications must be given timely and within one of three blocks of time
• Recall that all order/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
• Discuss patient safety issues with compounding pharmacies
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Laura A. Dixon 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. 

Continuing Education:
The Kentucky Hospital Research and Education Foundation is an approved Kentucky Board of Nursing continuing education provider. This offering number 5-0023-12-23-0-21 is approved for 2.4 contact hours. Participants must attend the entire session, complete the post-session evaluation, and provide nursing license number in order to receive contact hours and be awarded a certificate. No partial credit will be given. The Kentucky Board of Nursing Approval does not constitute endorsement of program content.

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