CMS Hospital Conditions of Participation Made Easy 2021 (part 3 of 5)

Time: 12:00 PM


Noon to 2 pm



IHA Members: $175 per organization
Non-IHA Members: $250 per organization

*Please note: The registration fee includes an unlimited number of connections per organization. Registrants will receive access to the program recording(s).

Offered through the Texas Hospital Association Foundation

Register Online

Back by popular demand!

A visit from the Centers for Medicare & Medicaid Services (CMS) can be stressful if you’re not prepared. A five-part webinar series designed for hospitals and health systems will cover every section of the CMS Hospital Conditions of Participation (CoP) manual, tailored to specific hospital departments. Although CMS is conducting limited surveys, prior to COVID hospitals had seen a significant increase in survey activity. Visits are especially underway following a complaint or indication of immediate jeopardy. This program will review the most problematic standards and offer tips for a gap analysis to ensure compliance—and help you prepare for your next CMS visit.

This is the third webinar in the five-part series.


  • Describe that medications must be given timely and within one of three blocks of time.

  • Recall that all protocols should be approved by the medical staff and an order entered into the medical record and signed off.

  • Recall that there are many pharmacy policies required by CMS.

  • Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record

  • Recall that the hospital must have a safe opioid policy approved by the Medical Executive Committee and staff must be educated about the policy.

Who Should Attend

This webinar series is designed for anyone involved with CoP compliance. This may include leaders and professionals in: 

  • Administration

  • Operations

  • Legal affairs

  • Clinical care: Nursing, Medicine, Pharmacy, Case Management, Rehabilitation, Infection Control and Radiology

  • Finance

  • Compliance

  • Quality improvement/Risk management

  • Facilities management

  • Board members

  • Health Information Management


Laura A. Dixon, JD, RN, CPHRM
Dixon has more than 20 years of clinical experience in acute care facilities. For the past six years she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC Companies. In this role she provided patient safety and risk management training to individuals and facilities. Dixon is a registered nurse and attorney.