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Advance Directives: Ensuring Compliance with CMS and TJC

November 12, 2020 @ 8:00 am - 10:00 am MST


Due to COVID-19, the registration is per hospital and not per connection for this webinar. Please only select a qty. of “1” under Registration and indicate the number of connections requested when completing the Attendee information.

A recording link of the webinar will be made available to all registrants for 60 days post-webinar.  

If Centers for Medicaid and Medicare Services (CMS) or The Joint Commission (TJC) showed up tomorrow, would you be in compliance with the advance directive requirements? Did you know there was a federal law that addresses advance directives? Did you know that CMS reimburses some physicians for advance care planning, or that better end-of-life care can reduce readmissions?

Advance care planning is making decisions about the care a patient wants to receive if they become unable to speak for themselves. While it was a big step for CMS to allow physicians to be compensated for advanced care planning, it is essential that practitioners understand the CMS advance directive requirements when doing advanced care planning.

This webinar will discuss the CMS hospital Conditions of Participation (CoPs) on advance directives along with The Joint Commission standards to help ensure compliance. The program will cover in detail advance directives such as living will, durable power of attorney, organ donation, mental health declaration, organ donor cards, patient advocates and do not resuscitate orders. It will discuss rights of patient representatives such as durable power of attorney (DPOA), support persons, parents or guardians. It will discuss the IHI conversation starter kit regarding discussions about end of life care, which has been downloaded over 100,000 times. We will also discuss how to talk to patients about end of life wishes, resources on advance care planning and the clinical prediction tool, Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL), to identify dying patients.

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

  • Recall that the CMS Conditions of Participation has requirements for advance directives for hospitals.
  • Discuss that CMS will now pay physicians to do advance care planning.
  • Describe that the Joint Commission has standards on advance directives.
  • Explain what is required of hospitals under the federal law called the Patient Self Determination Act.
  • Discuss the CMS has now issued a deficiency report that shows the number of hospitals out of compliance with the advance directive standards.
  • Discuss that information on the hospital’s advance directive policies must be given to inpatients, ED, observation, and same day surgery patients under the CMS CoP hospital manual.

Chief Nursing Officers, Compliance Officers, Ethics Committee Members, Social Workers, Discharge Planners, Consumer Advocates, Nurse Educators, Registration Staff, Ethicist,  Physicians, Chief Medical Officers, Nurse Managers, Nurse Supervisors, Risk Managers, Quality Improvement Directors, Joint Commission Coordinators, Hospital Legal Counsel, Directors of Registration, Palliative Care Physicians, Behavioral Health Staff, Psychiatrists, Patient Safety Officers, Outpatient and Emergency Department Managers, OR Directors, and Hospice Unit Staff 

Laura A. Dixon, BS, JD, RN, 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 patient safety and risk management 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 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.

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

November 5; 5:00 p.m. MDT

Access instructions and materials will be emailed to the person completing the order prior to the program date. If you do not receive the instructions at least 24 hours in advance, please contact IHA.


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November 12, 2020
8:00 am - 10:00 am MST
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