Hospital Conditions of Participation – Part 10

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Infection Prevention and Control and Antibiotic Stewardship Program, Plant and Physical Environment, Emergency Preparedness

This ten-part online seminar series will cover a majority of the CMS Hospital CoP manual – Appendix A. It is an excellent way to educate everyone in your hospital on all the sections of the CMS hospital manual, especially ones that apply to their department.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the 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.

Sections addressed include infection prevention and control and antibiotic stewardship program, QAPI, medical record services, dietary, utilization review, emergency services, surgical services, anesthesia, PACU, medical staff, nursing services, lab, rehabilitation, radiology, respiratory, physical environment, pharmacy, organ and tissue procurement, patient rights including restraint and seclusion, and discharge planning.

The interpretive guidelines serve as the basis for determining hospital compliance and though some changes from 2020 continue to have interpretive guidelines and survey procedures pending, hospitals are still expected to comply with the regulations. This program will include the 2020 changes, 2023 and 2024 updates and where some of the gaps continue – absence of interpretive guidelines and survey procedures, and any recent updates.

Registration Pricing

Member: $925 for entire series
Non-Member: $1175 for entire series
Registration includes unlimited connections per registered facility.

Register via PDF

Who Should Attend:

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.

Continuing Education

Continuing Medical Education
This educational activity is jointly provided by AXIS Medical Education and Texas Hospital Association. The Texas Hospital Association is applying for approval from the following accrediting organizations for the CMS CoPs 2025 Series.

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 1.0 contact hours each and 2.0 contact hours for March 27, 2025, session only.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

Click here for more information.

American College of Healthcare Executives
By attending the Critical Access Hospital (CAH) Conditions of Participation: Ensuring Compliance 2025 Webinar Series offered by Texas Hospital Association participants may earn ACHE Qualified Education Hours for each part in the series toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

Learning Objectives:

  • Discuss that CMS requires many policies in infection prevention and control
  • Recall the duties and responsibilities of the infection preventionist and leader of the antibiotic stewardship programs
  • Describe the need for facility maintenance program to include water management and ligature safety
  • Recall the necessary training and testing for a hospital’s emergency preparedness program

Faculty

Laura A. Dixon, BS, JD, RN, CPHRM, President, Healthcare Risk Education and Consulting, LLC, Denver, CO

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.

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.

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.

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.