2018 CMS Nursing CoP Standards for Hospitals: Proposed Changes and Updates

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
120 minutes
Product Description

Ensure Compliance in 2018 with the CMS Hospital Conditions of Participation in Nursing

Did you know that the Center for Medicare and Medicaid Services (CMS) has issued deficiency reports that includes the most problematic standards for hospitals? Did you know that according to the most recent report, nursing services have been cited over 4,000 times? Did you know there were eighteen recent memos of importance to nursing in the recent past? There have been many changes in the nursing chapter in the past years, and there are proposed changes in the Hospital Improvement Rule for 2018.

CMS made significant changes to IV medication administration, blood transfusion, safe injection practices, compounding, beyond use date (BUD) and implemented safe opioid standards. There are many other changes in the past to this section, which include timing of medications, standing orders, soft wrist restraints and restraint reporting, plan of care, verbal orders, self-administration of medications and drug orders. CMS has issued the final worksheets on QAPI, discharge planning and infection control that should be on the radar screen of all department managers. There are also proposed changes to the infection control worksheet.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS conditions of participation (CoPs) and it must be followed for all patients. Recently, there has been an increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Hospitals are still struggling with how to comply with these complicated standards. 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?

This session, with healthcare consultant Sue Dill Calloway, RN, MSN, JD, 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. Sue will cover the nursing services section in the hospital CoP manual. Sue will discuss the plans of care, staffing, policy changes, when an RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement and more.

The session will also reference other important sections that all nurses should be aware of 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. Sue will further cover the CMS issued privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

The session will discuss the 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 is used. Staffing, medications, three time frame for administering medications and educational requirements will be discussed along with the changes in standing orders and protocols. The session will cover CMS issued deficiency reports, so that hospitals are aware about the problematic tag numbers. This session will be useful for facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare, who must also follow these regulations.

Additional Handouts

  • CMS Manual Changes
  • CMS Memo on Texting
  • CMS Memo on Ligature Risk Policy

Session Highlights

This session will discuss:

  • CMS’s section on nursing services that every hospital must follow even if accredited
  • That all medications must be administered within three different time frames
  • How nursing care plans are a frequently cited area by CMS and a recent change
  • That all verbal orders must be signed off and need to include both a date and time
  • The focus by CMS on safe injection practices

Session Agenda

  • 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 starting at tag 385 and going 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

Who Should Attend

  • Chief nursing officers
  • All nurses
  • Nurse managers
  • Nurse supervisors
  • Nurse educators
  • HIM staff
  • Compliance officers
  • Chiefs of medical staff
  • Medical staff coordinators
  • Risk managers
  • Patient safety officers
  • Senior leadership
  • Documentation specialists
  • Hospital legal counsel
  • PI directors
  • Joint Commission coordinators
  • Regulatory officers
  • Legal counsel
  • Chief operating officers
  • Chief medical officers
  • Physicians
  • Education department staff
  • Board members
  • Directors of health information management
  • Audit staff
  • Others responsible for compliance with hospital regulations including documentation compliance

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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

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