Home Events Nursing Services Standards and Standing Orders; Protocols, and Order Sets: Meeting the CMS Hospital CoPs

Nursing Services Standards and Standing Orders; Protocols, and Order Sets: Meeting the CMS Hospital CoPs

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

Date: 4/26/22

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.


In 2020, the Centers for Medicare and Medicaid Services (CMS) made multiple changes to the hospital nursing chapter of the conditions of participation (CoPs), and further changes are anticipated. Specifically, the nursing CoPs section has been altered in response to the COVID-19 pandemic for “hospital at home” facilities.

This program will discuss the often-cited areas of the CoPs manual involving nursing care, including plans of care, staffing, policy changes, when an outpatient department requires a registered nurse (RN), documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement, and more.

CMS has issued deficiency reports on what are considered the most problematic standards for hospitals. Nursing services has been cited over 6,300 times, according to the most recent report. This is a must-attend program for any chief nursing officer, clinical nurse or nurse supervisor or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing.

Learning Objectives:

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

  • Recall that CMS has a section on nursing services that every hospital, even if accredited, must follow.
  • Describe the three timeframes in which all medications must be administered.
  • Discuss that nursing care plans are a frequently cited area by CMS.
  • Recite that verbal orders must be signed off and must include both a date and time.



Sharon Courage, RN, BSN, MPH, Senior Consultant
Nash Healthcare Consulting

Sharon Courage is a Registered Nurse with a Master’s in Public Health. Ms. Courage has thirty years of experience in hospital quality and risk management, quality improvement, development of hospital programs, patient safety, and acute and long-term care. From 2002 until the present, Ms. Courage served hospitals nationwide in developing programs and system improvements in patient safety, quality and risk management, infection control, program assessment, and accreditation preparation. She has assisted with the development and implementation of regulatory plans of correction, process development and implementation as well as process design for automation and electronic medical record documentation simplification. She has also assisted hospitals with assessment and strategy development and implementation to meet Joint Commission and CMS compliance including the development of sustainable strategies following conditional CMS survey findings.

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


Apr 26 2022


9:00 am - 11:00 am

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