CMS
Hospital Conditions of Participation
Made Easy 2019

AXIS Medical Education designates this continuing nursing education activity for 11.0 contact hours.

If a CMS surveyor showed up in your hospital tomorrow, would you be prepared? This day and a half program will cover the entire CMS Hospital CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that applies to their department.  Hospitals have seen a significant increase in survey activity by CMS. This program will discuss the most problematic standards.

This program will also include the proposed changes in 2019 on discharge planning and the IMPACT Act. CMS was given an extension to October 2, 2019 to implement these which will require massive changes. The hospital will need to get the discharge summary in the hands of the primary care physician within 48 hours. There are five new quality measures, five new things to add to the assessment form, medication reconciliation, providing written information on side effects of medication, five things that will have to be in the discharge instructions and more. 

The 2019 proposed changes in the Hospital Improvement Rule will be discussed. This makes many changes including a requirement for an antibiotic stewardship program and changes to nursing, medical records, QAPI, and more. CMS indicated they were going to pass this and were given a one year extension to implement it. This program will also talk about the 2019 changes to the validation survey process and the CMS proposed transparency changes. This includes changes to history and physicals, system wide QAPI and infection control, discretion on when an autopsy is indicated, and the role of non-physicians in psychiatric hospitals.

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. This 542 page manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital owned departments. Facilities accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV GL Healthcare must follow these regulations.

Changes in the recent past were made to the medical staff, board, texting of orders, ligature risk reduction, radiology, nuclear medicine, UR, nursing, pharmacy, dietary and outpatient regulations. There were changes to discharge planning, safe opioid use, IV medication, blood and blood products, safe opioid use, privacy and confidentiality, visitation, informed consent, advance directives, rehab and respiratory orders, radiology, QAPI, preventive maintenance, timing of medication, telemedicine, standing orders, informed consent, plan of care, humidity level, Complaint manual and reporting the accreditation organizations, organ procurement contracts, and adverse event reporting to the QAPI program. There were also a record breaking number of survey and certification memos issued over the past few years.

The October 12, 2018 changes affected hospitals with swing beds. The November 17, 2017 and December 29, 2017 changes will be discussed. Ligature risk and preventing suicidal patients from strangulation is being hard in the survey process. CMS has a proposed 15 page guideline on this for 2019. The November 20, 2015 manual implemented ten tag number changes in pharmacy and tag 405 in nursing. The July 10, 2015 manual rewrote all of the radiology and nuclear medicine sections. The October 9, 2015 included the definition of spouse for individuals of same sex marriages. 

The interpretive guidelines serve as the basis for determining hospital compliance and there have been many changes in the recent years. There have been significant changes and many important survey memos issued also. CMS issued the final surveyor worksheets for assessing compliance with the QAPI, infection control and discharge planning standards. The proposed changes to the infection control worksheet will be discussed. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance. 

There also are sections on medical record services, dietary, utilization review, emergency department, surgical services, anesthesia, PACU, medical staff, nursing services, outpatient department, rehabilitation, radiology, respiratory, physical environment, infection control, organ and tissue, patient rights and discharge planning. Hospitals should perform a gap analysis to ensure they are compliant with all these interpretive guidelines and assign one person to be responsible for ensuring compliance.

TUESDAY, November 19, 2019
7:30 a.m. Registration 
8:00 a.m. Welcome & Introductions
8:00 a.m. – 10:00 a.m.        CMS Conditions of Participation
10:00 a.m. – 10:15 a.m. BREAK
10:15 a.m. – 12:00 p.m. CMS Conditions of Participation (continued)
Noon – 12:30 p.m.         Lunch (provided)
12:30 p.m. – 2:00 p.m. CMS Conditions of Participation (continued)
2:00 p.m.- 2:15 p.m.         BREAK
2:15 p.m. - 4:30 p.m.         CMS Conditions of Participation (continued)

Objectives:
• Recall that CMS has restraint standards that hospitals must follow
• Describe that the patient has a right to file a grievance and the hospital must have a grievance policy and procedure in place
• Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical
• Describe that medications must be given timely and within one of three blocks of time
• Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
• Recall that there are many pharmacy policies required by CMS
• Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy
• Recall that CMS has patient safety requirements in the QAPI section that are problematic standards
• Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified
• Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state
• Discuss that CMS requires many policies in the area of infection control
• Recall that patients who are referred to home health and LTC must be given a list in writing of those available and this must be documented in the medical record
• Describe that all staff must be trained in the hospital’s policy on organ donation
• Understand that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment