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CMS Hospital Improvement Rules


Date: 7/11/23

9:00 – 11:00 A.M.  Central time


Registration fees:     $225 per facility   |   Non-Members Registration Fee:  $350 per facility


Chief Medical Officer, Chief Nursing Officer, 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 in the areas of nursing, history and physicals, infection control, QAPI, and orders for restraint and seclusion. The effective date was Nov. 29, 2019. The new rules require all hospitals to have an antibiotic stewardship program and dictate what the program should include. Additionally, there are care issues that are already a requirement in the Conditions of Participation. CMS has included these in the document because they deem them to be problematic in hospitals. CMS also clarified a number of existing requirements and federal regulations that are already final, making this webinar an excellent resource.


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

  • Recite that hospital antimicrobial stewardship programs have requirements in the CMS CoPs.
  • Discuss that CMS changed 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 that CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths.


Laura A. Dixon most recently served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. 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. Ms. Dixon has more than 20 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 in Napa, California. In this capacity, she provided patient safety and risk management 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, 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.

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




Jul 11 2023


9:00 am - 11:00 am

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