Home Events Informed Consent Update: Maneuvering the Maze

Informed Consent Update: Maneuvering the Maze

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

Date: 5/24/22

9:00 AM – Noon Central time


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


Informed consent and the applicable standards and guidelines can be confusing. The Centers for Medicare & Medicaid Services (CMS) and other accrediting organizations require certain elements to be included. This program will discuss the current CMS hospital Conditions of Participation (CoPs), including the critical access hospital, The Joint Commission (TJC) and DNV Healthcare standards on informed consent requirements. The CMS manual on CoPs h three sections regarding consent. All hospitals that receive Medicare and Medicaid reimbursement must comply with these regulations and the interpretive guidelines. Additionally, the CMS requirements for hospitals and critical access hospitals are very different and hospitals within a larger system should be familiar with the differences. This program will explain the differences in the requirements. Finally, health care providers must be aware of their specific state law on informed consent. Many professional organizations such as the American College of Surgeons, American Society of Anesthesiologists, and the American Association of Nurse Anesthetists also have guidelines or position statements on informed consent.

Learning Objectives:

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

  • Recall that the CMS hospital CoPs interpretive guidelines have three separate sections on informed consent.
  • Describe the six minimum requirements that are now mandatory to be on the informed consent form for surgery done at a hospital that receives Medicare reimbursement.
  • Discuss the CMS and accreditation organization standards applicable to your facility that should be reflected in the hospital’s policies and procedures.
  • Identify that the medical staff must have a list of procedures and tests that will require an informed consent under federal regulations.



Fred Fehlinger, BSN, RN, PHRN, EMTP
Nash Healthcare Consulting

Fred Fehlinger is an RN consultant for survey preparedness, on-site support and remediation for hospitals, ambulatory health care, critical access hospitals, long-term care and addiction/substance use programs under TJC, CMS, DNV and specific state programs. Fehlinger has expertise in quality, patient safety, infection control, case management, environment of care, emergency preparedness, medical staff, provision of care, patients’ rights, organizational leadership, and process improvement. In his previous hospital positions, he worked in senior leadership as a quality officer, market chief quality officer, regional director of survey readiness/quality, and director of quality and risk management for Community Health Systems.

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


May 24 2022


9:00 am - 11:00 am

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