Hospital Improvement Rule: What You Need to Know About the Final Changes

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
Conference Date
Tue, Feb 11, 2020
120 minutes
Product Description

Get Ready for Sweeping Hospital Compliance Changes

The final Hospital Improvement Rule from the Centers for Medicare & Medicaid Services (CMS) is effective as of Nov. 29, 2019 and will significantly change the way your hospital handles its compliance tasks regarding nursing, medical records, infection control, antibiotic stewardship, restraints, seclusion, Quality Assurance/Performance Improvement (QAPI), patient rights, and much more. You can’t let your hospital fall behind on updating its policies and procedures to comply with the new law.

The Hospital Improvement Rule effectively combines three laws into one – and with 393 pages, you have a lot of material to cover. Let expert speaker Sue Dill Calloway, RN, MSN, JD break down the key points and clue you in on the crucial changes contained in the final rule, so you can save your staff valuable time while ensuring compliance.

After attending this in-depth webinar session, you’ll walk away with all the tools and knowledge you’ll need to comply with the Hospital Improvement Rule. You’ll know exactly how to implement a now-required Antibiotic Stewardship Program and what that program should entail. You’ll also learn what CMS has found to be problematic in hospitals’ programs and CoP compliance. Additionally, you’ll hear about CMS clarifications on a variety of existing requirements and many federal regulations that are already final. This webinar is your one-stop source for your overall hospital compliance duties.

In this program, you will learn how to:

  • Get a copy of the CoP manual, survey memos, interpretive guidelines, and survey procedures;
  • Understand why the CoPs were revised;
  • Comply with the effective date for the key changes under the final rule (hint: this date is different for Critical Access Hospitals);
  • Understand the changes to requirements for progress notes for psychiatric hospitals and how often progress notes must be written;
  • Revise your policies and procedures regarding H&P, including when it’s required, medical staff requirements, assessments in healthy outpatients, and other considerations;
  • Update your hospital’s practices in light of changes to patient rights and medical records, including restraint changes, changes from LIP to LP, and PA requirements to order and evaluate;
  • Understand non-discrimination mandates under OCR 1557 – written policy, informing patients, filing complaints, and why CMS didn’t include this in the CoPs;
  • Get current on emergency preparedness – staff training every two years, exercises twice a year, EP policies and procedures, and your emergency plan;
  • Why CMS did not implement the medical records section with content of records, documentation of complications and hospital acquired conditions, diagnosis in outpatient record in seven days, and discharge instructions and transfer summaries;
  • QAPI changes: quality indicator data (including patient care data), Medicare quality reporting data, hospital readmission data, and hospital acquired conditions plus five changes;
  • Nursing services and outpatient departments: staffing (adequate number), supervisory staff, immediate response mandate, nursing care plans, policies and procedures, CNO evaluation of nursing staff, RN present in outpatient departments, outpatient policy required, MEC review of policies and procedures, orders for drugs and biologicals, and verbal orders;
  • Look back program and the lab: notification of tainted blood, patient notification process, and time frame for notification;
  • Autopsies: deleted requirement to get in unusual cases and coroner cases;
  • Swing-bed changes: dental, activity program and care plan assessment, social workers, and residents performing services;
  • Infection Control: hospital-wide surveillance, CDC outpatient assessment tools, following nationally recognized standards and best practices, infection control hospital-wide QAPI program, tracking all infections, QAPI leadership, competency-based staffing, and qualified infection preventionist; and
  • Antibiotic Stewardship Program: qualified leader appointed by the board, active program and evidence-based antibiotic use, document improvements and CDI reduction, board responsibilities, program leader responsibilities, and antibiotic stewardship policies.

Who Should Attend

This session will benefit, Chief Nursing Officers, nurses, nurse educators health information management staff, infection preventionists, antimicrobial stewardship team members, Chief Medical Officers, QAPI directors and staff, patient safety officers, regulatory and compliance officers, physician assistants (PAs),  patient advocates, risk management staff, nurse educators, hospital legal counsel, MEC chairs, board members, pharmacists and anyone involved in implementing the hospital CoPs.

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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 past VP of...   More Info
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