Description
CMS made some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. Changes include nursing, history and physicals, infection control, QAPI, and orders for restraint and seclusion. The new rules require all hospitals to have an antibiotic stewardship program and what the program should include. A great part of the Rule included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified several existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.
Objectives
- Recall that hospitals have requirements in the CMS CoPs on antimicrobial stewardship program
- Discuss CMS changes so PAs can order restraint and seclusion and do assessments if allowed by the hospital
- Describe that the hospital must have policies that describe which outpatient areas require a RN
- Discuss the changes for CAH QAPI program
Detailed Outline
Introduction
- Interpretive guidelines and survey procedure to be issued
- How to get a copy of the CoP manual, survey memos, etc.
Acute Hospitals
Restraints & seclusion
- Who can write orders
Psychiatric Hospitals
- Non-physicians writing in progress notes
- How often progress notes must be written
Emergency Preparedness
- Staff training every two years
- Exercises twice a year
- EP policies and procedures
- Emergency plan
QAPI
- Quality indicator data including patient care data
- Medicare Quality Reporting Data
- Hospital readmission data
H&P Changes
- When is a H&P required
- Assessments instead in healthy outpatients
- Medical staff policy requirements
- Considerations
Nursing Services
- Staffing-adequate number
- Supervisory staff
- Need to respond immediately when needed
- Nursing care plans
- Policies and procedures
- CNO must evaluate nursing staff including agency staff
- All outpatient departments must identify if RN must be present
- Outpatient policy required
- P&P must be reviewed by MEC
- Orders for drugs and biologicals
- Verbal orders
Look Back Program and the Lab
- Notification of tainted blood
- Patient notification process
- Time frame for notification
Infection Control and Antibiotic Stewardship
- Hospital wide surveillance
- CDC outpatient assessment tools
- Following national recognized standards and best practices
- Infection control hospital wide QAPI program
- Infection control program and policies requirements
- Qualified infection preventionist
- Requirements for the antibiotic stewardship program
- Qualified leader who must be appointed by the board
- Active program and evidenced based use of antibiotics
- Document improvements and reduction of CDI
- Board responsibilities
- Responsibilities of leader of antibiotic stewardship program
- Antibiotic stewardship policies
- Tracking all infections
- QAPI leadership
- Competency based staff training
Four swing bed changes
- Dental
- Activity program and assessment and plan of care
- Social worker
- Residents performing services
CAH Changes
Emergency Preparedness
Infection Prevention and Control and ASP
QAPI
Miscellaneous Changes
- Non-discrimination under OCR 1557
- Autopsies
Three Worksheets
Appendix and Resources
Who Should Attend?
- Chief Nursing Officer
- Pharmacist
- Health information management
- Infection preventionist
- Antimicrobial stewardship team members
- Nurses
- Nurse educators
- Chief medical officer
- QAPI director and staff
- Patient safety officers
- Regulatory and compliance officers
- Physician assistants (PAs)
- Risk management
- MEC chair
- Board members
- Anyone involved in implementing the hospital’s CoPs.
