Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2019 Update

Why Should You Attend:

Did you know there were over eighteen recent memos of importance to nursing in the recent past? Did you know there have been many changes nursing chapter in the past years including three proposed changes in 2019? The proposed changes are in the Hospital Improvement Rule. It will discuss plans of care, staffing, policy changes, when a RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement and more.

Did you know that CMS has issued deficiency reports which includes which are the most problematic standards for hospitals? Did you know that nursing services has been cited over 4,740 times according to the most recent report?

This is a must attend program for any clinical nurse or nurse leader or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing.

Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don’t be caught off guard and put your hospital’s reimbursement at risk. If a surveyor showed up at your door tomorrow, would you be prepared?

This program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, discharge planning standards and privacy and confidentiality.

Learning Objectives:

• Recall that CMS has a section on nursing services that every hospital must follow even if accredited
• Describe that all medications must be administered within three different time frames
• Discuss that nursing care plans are a frequently cited area by CMS and recall a recent change
• Recall that all verbal orders must be signed off and need to include both a date and time
• Recall that there is a focus on safe injection practices by CMS

Areas Covered in the Webinar:

• Introduction into the CMS hospital CoPs
• Where to locate a copy
• CMS deficiency reports and problematic standards
• How to get apprised of changes
• Changes to medication management, IV, blood, and opioid safe use
• Proposed changes under the Hospital Improvement Act
• ISMP IV push guidelines
• Safe injection practices
• Changes related to safe injection practices, compounding, medication preparation, immediate use, and labeling
• Revised CMS Hospital work sheets and importance
• CMS memos of interest
• Rewrote all the discharge planning standards
• Hospital deficiencies
• Reporting to the PI system
• Insulin pens and safe injection practices
• New interpretive guidelines
• Luer misconnections
• Organ Procurement Organization Contracts
• Discharge planning standards
• CMS complaint manual
• Humidity in the OR
• Federal regulation changes
• Final interpretive guidelines and changes
• Most current CMS Manual
• Many recent changes to 9 tag numbers
• Starts at Tag 385 and goes to tag 413
• Nursing Services and 24 hours services
• Third revised worksheet
• RN on duty
• Integrated with hospital wide PI program
• Organizational chart and nursing
• Chief Nursing Officer (CNO) responsibilities
• CNO requirements
• CNO approval of nursing policies
• Staffing and delivery of care
• 24 hour nursing services and supervision
• Valid license for nurses and verification
• RN to evaluate to care of all patients
• Nursing care plans
• Changes to the plan of care
• Agency nurse requirements
• Orientation of agency nurses
• Medication administration
• Order required for all medications
• Standards of care and practice to prevent HAI
• BUD, compounding sterile preparations (CSP)
• Immediate use CSP
• Administration one hour rule
• Safe injection practices
• Standing orders and protocols
• Three medications timing changes
• Protocols, standing orders, order sets
• Tag 405 standards moved to 457
• Requirements for complete drug order
• Verbal orders and verbal orders changes
• Blood transfusions and IV medications changes
• Self-administered medications

Who Will Benefit:

• Chief Nursing Officer
• Nurse Managers
• Nurse Supervisors
• Nurse Educator
• HIM staff
• Compliance Officer
• Chief of Medical Staff
• Medical Staff Coordinator
• Risk Manager
• Patient Safety Officer
• Documentation Specialist
• Hospital Legal Counsel
• PI Director
• Joint Commission Coordinator
• Regulatory Officers
• Chief Operating Officer
• Chief Medical Officer
• Physicians
• Education Department Staff
• Board Members
• Director of Health Information Management
• Audit Staff
• Others responsible for compliance with hospital regulations including documentation compliance

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

Ms. Calloway has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

Topic Background:

CMS made significant changes to IV medication administration, blood transfusion, safe injection practices, compounding, beyond use date (BUD) and implemented safe opioid standards. Hospitals are still struggling how to comply with these complicated standards.

There are many changes in the past to this section include timing of medications, standing orders, soft wrist restraints and restraint reporting, plan of care, verbal orders, blood transfusions, IV medication, compounding, BUD, safe injection practices, self-administration of medications and drug orders. There were many changes to the final interpretive guidelines that went into effect the past two years. CMS has issued the final worksheets on QAPI, in nursing.

Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don’t be caught off guard and put your hospital’s reimbursement at risk.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.

Note: CMS has a separate CoP for critical access hospitals (CAHs). Although there are now many similar standards in the nursing services section it is important to note that CMS has a separate manual for CAHs and differences do exist. Major differences are discussed throughout the program.

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