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Meeting CMS CoP and TJC Standards

Medical Staff, Telemedicine and Other Changes: 
Meeting CMS Conditions of Participation and TJC Standards

Tuesday, August 31, 2021
9:00 am - 10:30 am CST

Offered Through Partnership with Georgia Hospital Association

Course Curriculum:
There are over 2,180 deficiencies from the Centers for Medicare & Medicaid Services (CMS) related to the medical staff section. Three significant changes became effective on November 29, 2019 to the CMS Conditions of Participation (CoPs) under the transparency bill, discharge planning and hospital improvement rule, all of which will be discussed in this webinar. This discussion will include changes to the history and physicals for healthy patients having outpatient procedures as well as changes to the autopsy rules. The board and medical staff sections will be considered in detail. There will also be a concurrent discussion of the Joint Commission (TJC) standards for medical staff. 

Although telemedicine has been a factor in healthcare for many years, COVID-19 gave it a larger role in diagnosis and treatment of patients. It is anticipated that the telemedicine boom will outlive the coronavirus. CMS has made many changes to the regulatory standards of telemedicine during the COVID-19 pandemic. These standards, along with the 1135 telemedicine waivers, and the new tag numbers for critical access hospitals in 2020 and 2021 will be covered in this presentation.

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

  • Recall that CMS has a section related to the medical staff.
  • Articulate that hospitals can have a separate medical staff or a unified shared and integrated medical staff.
  • Recall that CMS will allow the Medical Staff to credential qualified non-physicians to write orders, if state law allows.
  • Recite the requirements for a medical staff under TJC standards.
  •  Explain the Joint Commission standards on telemedicine.

Target Audience:
Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Joint Commission Coordinator, Quality Improvement personnel, Risk Manager, Legal Counsel.

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states. 

Ms. Dixon has more than twenty 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, Napa, California.  In this capacity, she provided 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, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing.  She is licensed to practice law in Colorado and California.  


8/31/2021 9:00 AM - 10:30 AM
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