CMS Nursing CoP Standards for Hospitals: 2016 Update

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

Review 2016 Updates for CMS Nursing CoP Standards for Hospitals


Did you know there were fifteen recent memos of importance to nursing in the recent past? Are you aware of the many changes in nursing chapter, and that CMS has issued deficiency reports which includes the most problematic standards for hospitals?

Join expert speaker Sue Dill Calloway, RN, MSN, JD in this must-attend webinar for clinical nurses or nurse leaders in ensuring compliance with the CMS hospital conditions of participation (CoPs). There has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. CMS issued a 32 page memo which went into effect June 6, 2014 and it made noteworthy changes to IV medication administration, blood transfusion, and implemented safe opioid standards. Hospitals are still stressed 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, self administration of medications and drug orders. There were many changes to the final interpretive guidelines that went into effect in the past two years. CMS has issued the final worksheets on QAPI, discharge planning and infection control which should be on the radar screen of all department managers.

In this session, Sue will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations. This 90-minute program will also cover medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, discharge planning standards and privacy and confidentiality.

CMS has issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo. These sections contain 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 in standing orders and protocols. CMS has started issuing deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.

Detailed Agenda:

  • Review of the CMS hospital CoPs
  • Find out where to locate a copy
  • Insights on CMS deficiency reports and problematic standards
  • Learn how to get apprised of changes
  • Changes to medication management, IV, blood, and opioid safe use
  • Revised CMS Hospital work sheets and importance
  • Recent CMS memos of interest
    • Rewrote all the discharge planning standards
    • Hospital deficiencies
    • Reporting to the PI system
    • Insulin pens and safe injection practices
    • New interpretive guidelines
    • Luer misconnections
    • Organ Procurement Organization Contracts
    • Discharge planning standards
    • CMS complaint manual
    • Humidity in the OR
  • Review of Federal regulation changes, and Final interpretive guidelines and changes
  • Most current CMS Manual
  • Insights on many recent 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 and 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, and changes to the plan of care
  • Agency nurse requirements, and orientation of agency nurses
  • Medication administration; Order required for all medications; 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, and Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self administered medications

Other sections nurses should be aware of:

  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation
  • History and physicals

Learning Objectives

  • Understand that CMS has a section on nursing services that every hospital must follow even if accredited.
  • Know that all medications must be administered within three different time frames.
  • Understand that nursing care plans are a frequently cited area by CMS and recall a recent change.
  • Know that all verbal orders must be signed off and need to include both a date and time.

Who Should Attend?

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.


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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
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