The CMS Hospital Improvement Act Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI, 5 Star Rating Program and More!

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
Conference Date
Tue, Oct 04, 2016
90 minutes
Product Description

Learn about all the changes to Hospital Improvement Act brought forward by CMS


CMS has proposed some significant changes to the hospital conditions of participation (CoPs) that every hospital should know including critical access hospitals. This includes changes to nursing, medical records, infection control, QAPI, patient rights, restraint and seclusion, and the 5 Star Rating System. It will also require all hospitals to have an antibiotic stewardship program which will include a prohibition on discrimination, which must be given to patients in writing.

CMS created the 5 Star Rating System to help patients and their families identify areas whey they might want to ask questions. This was added to the hospital compare website. Only 7% (251) of the 3,553 hospitals earned a full 5-star rating. A little over one third of hospitals (1,205) received a 4-star rating, while 40% (1,414) received 3 stars, 2 stars were given to 16% (582), and 3% (101) received a 1-star rating.

This session by expert speaker, Sue Dill Calloway, RN, MSN, JD, discusses the proposed changes to the CMS Hospital Improvement Act, including the recent five star rating system, infection control, the Antibiotic Stewardship Program, QAPI.

Learning Objective

  • Recall that hospitals will have to implement an antimicrobial stewardship program
  • Discuss that CMS proposes to change LIP to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments
  • Describe that the hospital must have policies that describe which outpatient areas require a RN
  • Recall that a final diagnosis would have to be in the medical record for all outpatients within 7 days
  • Explain that CMS has a 5-star rating system for hospitals on hospital compare


Patient Rights and Medical Records

  • Five Changes in Restraint
  • Change from LIP to licensed practitioner (LP)
  • Physician Assistants (PAs) to order and evaluate
  • Right to access medical records—Oral or written
  • OCR 2016 2 documents
  • Non-discrimination
    • Written policy prohibiting
    • Inform each patient on prohibition against discrimination
    • Inform on how to file a complaint
  • Medical Records
    • Content of medical records
    • Document complications and hospital acquired conditions
    • Diagnosis in outpatient record in 7 days
    • Final diagnosis
    • Discharge instructions and transfer summaries
    • Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
    • Information to monitor patient conditions


  • Quality indicator data including patient care data
  • Medicare Quality Reporting Data
  • Hospital readmission data
  • Hospital acquired conditions (HACs) and 5 changes

Nursing Services and Outpatient Departments

  • 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
  • Annual review of P&P
  • Orders for drugs and biologicals
  • Verbal  orders

Infection Control and Antibiotic Stewardship

  • Hospital wide surveillance
  • 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

CMS 5-Star Rating System

  • Why it was started?
  • Hospital Compare
  • Percentage of hospitals getting a 5 star rating

Who should attend?

  • Pharmacist
  • Chief nursing officer
  • Health information management
  • Infection preventionist
  • Antimicrobial stewardship team members
  • Nurses
  • Nurse educators
  • Chief medical officer
  • QAPI staff
  • Patient safety officers
  • Regulatory and compliance officers
  • Physician assistants (pas)
  • Patient advocate
  • Risk management
  • Nurse educators
  • Hospital legal counsel
  • MEC chair
  • Board members
  • Anyone involved in implementing the hospitals cops
  • Anyone who is interested in the CMS 5-star rating system

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

Order Below or Call 1-866-458-2965 Today

You can also order through:




About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a 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...   More Info
More Events By The Speaker

Why AudioEducator?
  • Save money on travel.
  • Meet your specific training needs.
  • Keep learning after the event.
  • Save time training your whole staff.
Join Our Mailing List
Our Accreditation Partners
Facebook Twitter Linkedin Youtube RSS Feeds Google Plus
Audio Educator


Dear Valued Customers


We regret to announce that ProEdTech LLC and all its affiliate brands will cease operations on April 1, 2019.


We are no longer able to fulfill online orders. We will fullfill all DVD and book orders already placed.


Customers of canceled webinars and subscription products may request a refund at (800) 223-8720 or You must do so by April 1, 2019.


Thank you for your business and loyalty over the years. We sincerely apologize for any inconvenience caused.


Best regards,

The ProEdTech Team