Education Events banner WF


Nov. 14, 2023


9:00am - 11:00am



Coupon-eligible, Virtual

CMS Hospital Surgery, Anesthesia and PACU CoPs Requirements — Virtual Event


chief medical officers, chief nursing officers, compliance officers, emergency department personnel, TJC coordinators, medical records staff, quality improvement personnel, risk managers and legal counsel

The following program content was provided by the speaker.


This program will cover the Centers for Medicare & Medicaid Services hospital Conditions of Participation standards for surgery, anesthesia and post-anesthesia care unit.

The event will discuss important CMS memos that impact care in the operating room, including safe injection practices and infection control breaches with IV medications. Guidance from the Institute for Safe Medication Practices and Centers for Disease Control and Prevention also will be provided.

During the event, participants 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; current CMS guidelines; and interpretive guidelines regarding pre-anesthesia evaluations, post-anesthesia evaluations and anesthesia services.


Upon completion of this program, participants will 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 CMS requirements included in the OR register
  • describe information that is required for 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, RN, MSN, NEA-BC, has more than 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. Seeley has helped organizations achieve continuous survey readiness and assists organizations with writing and implementing successful Plans of Corrections for survey deficiencies. She also has assessed quality programs, clinical operations, the structure and function of medical staff committees, and the implementation of peer review quality plans.

Before becoming a consultant, Seeley 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, Fla. She is a registered nurse with an Advanced Nurse Administrator certification through the American Nurses Association.

General Information

This educational activity is provided by MHA Health Institute in collaboration with the Georgia Hospital Association.

MHA Health Institute

General Information


Register on or before Monday, Nov. 13, to ensure the delivery of instructional materials.



  • $225 per person for MHA members
  • $325 per person for nonmembers

This virtual event is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA member hospital CEOs in December 2022.

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

This educational activity is provided by MHA Health Institute in collaboration with the Georgia Hospital Association.

Event Contact

Karyn Bonney

Karyn Bonney

Education Specialist

Send Email

573-893-3700 | ext. 1384

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