CMS Hospital Surgery and PACU Standards: Are You in Compliance?

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute
Health Institute

Date & Time

Tuesday, Dec. 11
9 - 11 a.m.

Register on or before Tuesday, Dec. 4, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation.


Hospital staff involved with CMS surgery, anesthesia and post-anesthesia care unit compliance regulations and guidelines, including but not limited to, CMOs, CNOs, anesthesiology personnel, physicians, nurses, patient safety officers, risk managers, compliance officers, legal counsel and any staff involved in assisting with cases of anesthesia and moderate sedation.

The following program content was provided by the speaker.


This webinar will review the Centers for Medicare & Medicaid Services hospital Conditions of Participation standards for surgery, anesthesia and PACU. Topics include some of the important CMS memos that discuss medication management, IV and safe opioid use, as well as the current interpretive guidelines regarding pre- and post-anesthesia evaluations and services. The speaker also will identify the types of deficiencies hospitals receive in the areas of informed consent, H&Ps, safe opioid use, safe injection practices, compounding and beyond-use dates.


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

  • identify the policies and procedures required by CMS related to surgery and anesthesia services
  • discuss the section in the CMS manual that addresses PACU requirements
  • identify items listed in the CMS manual that must be included in the OR register
  • describe the information required for an informed consent that should be on the chart before surgery
  • discuss the inpatient and outpatient 48-hour requirements for the post-anesthesia evaluation


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians and other health care providers. Dill Calloway has authored more than 100 books and numerous articles. She is a frequent speaker and is well known across the country in the area of health care law, risk management and patient safety.