CMS Hospital Conditions of Participation Made Easy 2021 (part 5 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 final webinar in the five-part series.


  • Discuss that CMS requires many policies in the infection control area.

  • Recall that patients who are referred to home health, inpatient rehabilitation, long-term care hospitals (LTCH) and long-term care (LTC) must be given a list in writing of those available and this must be documented in the medical record.

  • Describe that all staff must be trained in the hospital’s policy on organ donation.

  • Understand that CMS has specific things that are required to be documented in the medical record regarding the post-anesthesia assessment.

  • Recall that CMS has finalized the discharge planning worksheet and changes to the standards.

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.