Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2021 Update

January 27, 2021
90 Mins
Laura A. Dixon
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Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2021 Update

There were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020 and it is anticipated there will be additional changes in 2021. There have been over eighteen CMS survey memos of importance issued relating to nursing in the recent past. The final changes were in the Hospital Improvement Rule. This program will discuss 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.

CMS has issued deficiency reports which include the most problematic standards for hospitals. The nursing services have been cited over 5,635 times according to the most recent report. This webinar by industry expert Laura A. Dixon, BS, JD, RN is a must-attend program for any chief nursing officer, clinical nurse, or nurse supervisor, or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. Laura will discuss the deficiencies and how hospitals can ensure compliance.

CMS made previous revisions to IV medication administration, blood transfusion, safe injection practices, compounding, beyond-use date (BUD), and implemented safe opioid standards. Hospitals continue to struggle with how to comply with these complicated standards, especially the safe opioid interpretive guidelines.

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, compounding, BUD, antibiotic stewardship program, safe injection practices, self-administration of medications and drug orders. 

CMS also issued the final worksheets on QAPI, discharge planning, and infection control which should be on the radar screen of all department managers especially because there were changes in 2020 in all these sections and with interpretive guidelines and survey procedures still to be decided by CMS. There are also proposed changes to the infection control worksheet which will be discussed.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. Laura will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV GL Healthcare must also follow these regulations.

During the webinar, Laura will also reference other important sections that all nurses should be aware of that are found outside the nursing services section such as the revised discharge planning standards, medication standards, revised history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

This section contains 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, a three-time frame for administering medications, and educational requirements will be discussed along with changes in standing orders and protocols. CMS starting issuing deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.

Webinar Objectives
  • Recall that CMS has a section on nursing services that every hospital must follow even if accredited 
  • Describe that all medications must be administered within three different time frames
  • Discuss that nursing care plans are a frequently cited area by CMS 
  • Recall that all verbal orders must be signed off and need to include both a date and time
  • Recall that there is a focus on safe injection practices by CMS
Webinar Agenda
  • Introduction into the CMS hospital CoPs
  • Where to locate a copy (new website)
  • Email address of CMS to ask questions
  • CMS deficiency reports and problematic standards
  • How to keep apprised of changes
  • Changes to medication management, IV, blood, and opioid safe use
  • Final changes under the Hospital Improvement Rule to nursing        
  • ISMP IV push guidelines
  • Safe injection practices
  • Changes related to safe injection practices, compounding, medication preparation, immediate use, and labeling
  • CMS Hospital worksheets 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
    • Organ Procurement Organization Contracts
    • Discharge planning standards
    • CMS complaint manual
    • Humidity in the OR
  • Reporting requirements under COVID-19 pandemic
  • CDC resources on preventing HAI
  • Nursing Services and 24 hours services
  • 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
  • A valid license for nurses and verification
  • RN to evaluate the care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • The orientation of agency nurses
  • Medication administration
  • The order required for all medications
  • OCR Section 1557 and 2020 changes
  • 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
  • Requirements for complete drug order
  • Verbal orders
  • Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self-administered medications
Who Should Attend
  • Chief Nursing Officer
  • All Nurses
  • Nurse Managers
  • Nurse Supervisors
  • Nurse Educators
  • HIM staff
  • Compliance Officer
  • Chief of Medical Staff
  • Medical Staff Coordinator
  • Risk Manager
  • Patient Safety Officer
  • Senior Leadership
  • COO
  • Documentation Specialist
  • Hospital Legal Counsel
  • QAPI 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 Nursing Regulations including documentation Compliance
Laura A. Dixon

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining...
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