Training Course Syllabus:

Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2017 Update Webinar

Did you know there were fifteen recent memos of importance to nursing in the recent past? Did you know there have been many changes in nursing chapter in the past two years including 2016 changes and proposed changes in 2017? The proposed changes are in the Hospital Improvement Act. Did you know that CMS has issued deficiency reports which includes which are the most problematic standards for hospitals?

Significant changes were made by CMS to blood transfusion, compounding, safe injection practices, IV medication administration, beyond use date (BUD) and implemented safe opioid standards. Hospitals are still facing issues on ways to comply with these complicated standards. There have been many changes in the past to this section which includes drug orders, self administration of medications, safe injection practices, compounding, IV medication, blood transfusion, verbal orders, plan of care, soft wrist restraints and restraint reporting, standing orders and timing of medications. Many changes to the final interpretive guidelines went into effect in the past two years. The final worksheets on QAPI, discharge planning and infection control, which should be on the radar screen of every department managers, has been issued by the CMS.

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
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. 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. This webinar will also discuss staffing, medications, three time frame for administering medications and educational requirements, along with changes in standing orders and protocols. Lastly, it will cover the CMS´ issue of deficiency reports 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
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
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

Who will 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.

Seminar Summary:

This session by expert speaker Sue Dill Calloway, RN, MSN, JD, is a must attend for any clinical nurse or nurse leader or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. There has been an increase in surveillance and scrutiny in recent times to ensure that every hospital is in compliance with the hospital CoPs. Don't take chance and put your hospital's reimbursement at stake. (see full course description)

print this agenda