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CMS Hospital Improvement Rules

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 4/19/22

9:00 – 11:00 AM Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member

Target Audience

CMO, CNO, Compliance Officer, Emergency Department personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.

The Centers for Medicare & Medicaid Services (CMS) made significant changes to the hospital conditions of participation (CoPs), including nursing, history and physicals, infection control, QAPI, and orders for restraint and seclusion. While the effective date for the changes to take place was November 29, 2019, Critical Access Hospitals had until end of March 2021 to implement a QAPI program as those requirements were completely rewritten.

The new rules require all hospitals to have an antibiotic stewardship program, the core elements of which the Centers for Disease Control and Prevention (CDC) revised in November 2019. A large part of the rule included areas that are already a requirement in the hospital CoPs. This session will cover several existing requirements clarified by CMS along with several finalized federal regulations, making this webinar an excellent resource for all hospital employees.

Learning Objectives:

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

  • Recall that hospitals have requirements in the CMS CoPs on antimicrobial stewardship program.
  • Discuss CMS changes allowing PAs to order restraint and seclusion and do assessments if allowed by the hospital.
  • Recite the hospital policies describing which outpatient areas require a registered nurse (RN).
  • Describe the changes for CAH QAPI program.



Lena Browning, MHA, BSN, RNC-NIC, CSHA
Nash Healthcare Consulting

Lena Browning is a nurse leader and accreditation specialist with more than twenty-five years of experience in clinical leadership in acute care settings. As a Principal Consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled 3 Interim positions as Director of Accreditation and was responsible for restructuring accreditation departments and leading organizations in continuous compliance and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy situations with all organizations getting the IJ lifted, and no condition level findings noted on return surveys. Prior to consulting, Lena had over 2 decades of experience in Accreditation and Regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired, and facilitated continuous readiness committees, and coached staff and leadership in effective compliance and performance  improvement strategies. Additionally, Lena has extensive experience in Quality and Patient Safety, Performance Improvement, Medical Staff Credentialing and Privileging, Contract Management, and Strategic Planning for Hospitals and Home Care Agencies. Lena earned her Master of Healthcare Administration from the University of Southern Indiana and her Bachelor of Science in Nursing from Murray State University. She is a Registered Nurse Certified in Neonatal Intensive Care, a Certified Specialist in Healthcare Accreditation, and holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post resuscitation stabilization. She is also a member of the Association for Professionals in Infection Control and Epidemiology (APIC).

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


Apr 19 2022


9:00 am - 11:00 am

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