CMS Nursing CoP Standards for Hospitals: 2016 Update

Duration: 120 Minutes
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Did you know there were fifteen recent memos of importance to nursing in the recent past? Did you know there have been many changes nursing chapter in the past two years including 2016 changes? Did you know that CMS has issued deficiency reports which includes which are the most problematic standards for hospitals? 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.
Hospital Regulatory Compliance
Instructor: Sue Dill Calloway
Product ID: 501289
Objectives of the Presentation
  • 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
Why Should you Attend
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.

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 with how to comply with these complicated standards.

There are many changes in the past to this section including 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, discharge planning and infection control which should be on the radar screen of all department managers.

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, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations.

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. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols. CMS starting issuing deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.

Areas Covered
  • 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
  • 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
  • Recent 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
  • Insulin pen and safe injection practices
  • 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
  • Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self administered medications
Other important sections nurses should be aware of:
  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation
  • History and physicals
*Note: CMS has a separate CoP for critical access hospitals (CAHs). Although there are 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.

Who can Benefit
Chief nursing officer, all nurses, nurse managers, nurse supervisors, nurse educator, HIM staff, compliance officer, chief of medical staff, Medical staff coordinator, risk manager, patient safety officer, senior leadership, documentation specialist, hospital legal counsel, PI director, Joint Commission coordinator, regulatory officers, legal counsel, chief operating officer, chief medical officer, physicians, education department staff, board members, director of health information management, audit staff, and others responsible for compliance with hospital regulations including documentation compliance.
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Instructor Profile:
Sue is president of Patient Safety and Healthcare Consulting and Education company with focus on medical legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.
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