This webinar will review the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) for surgery, anesthesia, and post-anesthesia care units (PACU), including the most commonly cited deficiencies and how to avoid them. This program will cover some of the important CMS memos that discuss safe injection practices and infection control breaches with IV medications. Guidance from the Institute for Safe Medication Practices (ISMP) and the Centers for Disease Control and Prevention (CDC) will also be provided.

We will review how the CMS guidelines affect sedation done in the emergency department and GI lab, as well as the current interpretive guidelines regarding pre-anesthesia evaluations, post-anesthesia evaluation and anesthesia services. You will also learn the cause for delays of 10% of surgical procedures and how to avoid an average loss of $600,000 a year due to these delays.

Director of Anesthesia, Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Surgery Director, Quality Improvement personnel, Risk Manager, Legal Counsel.


At the conclusion of this session, participants should be able to:

  • Recall that there are several policies and procedures required by CMS related to surgery and anesthesia services.
  • Describe that CMS has a section addressing PACU requirements.
  • Recall that CMS has a list of items that must be included in the OR register.
  • Explain what information is required for an informed consent and that it should be on the chart before surgery.
  • Discuss the 48-hour requirements for the post-anesthesia evaluation of both inpatients and outpatients.


Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states.

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 consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing.  She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.