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Who should attend 2018 CMS Nursing CoP Standards for Hospitals: Proposed Changes and Updates
Chief nursing officer, all nurses, nurse managers, nurse supervisors, nurse educator, HIM staff, compliance officer
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Training Course Syllabus:


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. 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. 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 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. CMS has issued the final worksheets on QAPI, discharge planning and infection control which should be on the radar screen of all department managers. There are also proposed changes to the infection control worksheet which will be discussed.

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
Recall that there is a focus on safe injection practices by CMS

Why Should you Attend

Did you know there were 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 the proposed changes in 2018? 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 4,350 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. This is a must attend program and will discuss the deficiencies and how hospitals can ensure compliance.

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?

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 Rule
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
Hospital deficiencies
Safe injection practices
Legionnaire’s
Reporting to the PI system
Insulin pens and safe injection practices
New interpretive guidelines
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
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
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:

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