Home Events CMS Hospital Surgery, Anesthesia, and PACU CoPs Requirements

CMS Hospital Surgery, Anesthesia, and PACU CoPs Requirements

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

Date: 11/8/22

9:00 – 11:00  AM Central time


Registration fees:       $225 per NDHA member  |  $275 per non-member


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

Course Curriculum:

This program will cover the Centers for Medicare & Medicaid Services (CMS) hospital Conditions of Participation (CoPs) standards for surgery, anesthesia, and the Post Anesthesia Care Unit (PACU). The webinar will discuss important CMS memos that impact care in the operating room, 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. This webinar will also review changes to the history and physical (H&P) that went into effect in November 2019, including the option that hospitals can elect to do an assessment on healthy outpatients undergoing surgery or a procedure instead of an H&P.

This program will examine the number of reported CMS deficiencies and types received by hospitals, including informed consent, H&Ps, and safe injection practices. The many standards required by the surgery department and anesthesia will be addressed, including required policies, the current CMS guidelines, interpretive guidelines regarding preanesthesia evaluations, post-anesthesia evaluation, and anesthesia services.

Learning Objectives:

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 that addresses PACU requirements.
  • Recite what CMS requires to be included in the OR register.
  • Describe what information is required for an informed consent and that this information should be on the chart before surgery.
  • Discuss the 48-hour requirements for the post-anesthesia evaluation of inpatients and outpatients.


Susan Seeley has over 40 years of experience in the health care industry, both as a nurse leader and as a clinical consultant with a focus on patient care services and regulatory compliance. She is experienced in conducting mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education. Susan has helped organizations achieve continuous survey readiness and assists organizations with writing and implementing successful Plans of Corrections for survey deficiencies. She has also assessed quality  programs, clinical operations, the structure and function of medical staff committees, and the implementation of peer review quality plans. Prior to becoming a consultant, Susan spent 19 years as the chief nursing officer for a rural Florida hospital while working part time for the parent company as a clinical consultant for their more than 200 hospitals. She earned her Master of Science in Nursing Administration and her Bachelor of Science in Nursing from Barry University in Miami Shores, Florida. She is a registered nurse and holds an Advanced Nurse Administrator certification through the American Nurses Association.


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



Nov 08 2022


9:00 am - 11:00 am

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