CMS finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This includes changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. The effective date was November 29, 2019. The new rule requires all hospitals to have an antibiotic stewardship program and what the program should include among other requirements. A great part of this document included care issues that CMS has found to be problematic in hospitals that are already a requirement within the Conditions of Participation. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource. Register Now, https://conferencepanel.com/conference/cms-hospital-improvement-final-rules-nursing-medical-records-infection-control-and-more

1. CMS Hospital Improvement
FINAL Rules
Nursing, Medical Records, Infection Control
Antibiotic Stewardship Program, Restraints, QAPI, and more
Speaker - Laura A. Dixon

2. About Speaker
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
consulting and training to facilities, practitioners, and staff in multiple states. Such services included the
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 representation of clients for Social Security Disability Insurance
providing legal counsel and representation at disability hearings and appeals, medical malpractice
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.

3. Description
CMS finalized some significant changes to the hospital conditions of participation (CoPs)
that every hospital should know, including critical access hospitals. It was 393 pages long
and combined three laws into one. This includes changes to nursing, medical records,
infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. The effective
date was November 29, 2019.
The new rule requires all hospitals to have an antibiotic stewardship program and what the
program should include among other requirements. A great part of this document included
care issues that CMS has found to be problematic in hospitals that are already a
requirement within the Conditions of Participation.

4. Learning Objectives
▪ Recall that hospitals have requirements in the CMS CoPs on antimicrobial
stewardship program
▪ Discuss that CMS change the term LIP (licensed independent practitioner) to LP
(licensed practitioner) so PAs can order restraint and seclusion and do assessments if
allowed by the hospital
▪ Describe that the hospital must have policies that describe which outpatient areas
require an RN
▪ Recall CMS removed the section that required hospitals to conduct autopsies in cases
of unusual deaths

5. Session Outline
▪ Overview of the changes
▪ QAPI
▪ Psychiatric Hospitals
▪ Patient Rights and Medical Records
▪ Emergency Preparedness
▪ H&P Changes
▪ Look Back Program and the Lab
▪ Nursing Services and Outpatient Departments
▪ Autopsies
▪ Four swing bed changes
▪ Infection Control and Antibiotic Stewardship
▪ Critical Access Hospital

6. Who Should Attend
▪ Pharmacist
▪ Chief nursing officer
▪ Health information manager
▪ Infection prevention
▪ Antimicrobial stewardship team members
▪ Nurses
▪ Nurse educators
▪ Chief medical officer
▪ QAPI director and staff
▪ Physician assistants (PAs)
▪ Patient advocate
▪ Risk management
▪ MEC chair
▪ Anyone involved in implementing the
hospital's CoPs
▪ Patient safety officers
▪ Regulatory and compliance officers

7. To Learn More
Register Now