CMS finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This includes changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. The effective date was November 29, 2019.

The new rule requires all hospitals to have an antibiotic stewardship program and what the program should include, among other requirements. A significant part of this document included care issues that CMS found problematic in hospitals that are already a requirement within the Conditions of Participation. CMS also clarified several existing conditions and several federal regulations that are already final, making this webinar an excellent resource.

Learning Objectives:-

• Recall that hospitals have requirements in the CMS CoPs on antimicrobial stewardship program
• Discuss that CMS change the term LIP (licensed independent practitioner) to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments if allowed by the hospital
• Describe that the hospital must have policies that describe which outpatient areas require a RN
• Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths

Detailed Outline:-

Introduction

• Overview of the changes
• How to get a copy of the CoP manual, survey memos, etc.
• Why revise the CoPs

QAPI

• Quality indicator data, including patient care data
• Medicare Quality Reporting Data
• Hospital readmission data
• Hospital-acquired conditions (HACs) with five changes

Psychiatric Hospitals

• Non-physicians writing in-progress notes
• How often progress notes must be written

Patient Rights and Medical Records

• Restraint changes
• Change from LIP to licensed practitioner (LP)
• Physician Assistants (PAs) to order and evaluate     
• Non-discrimination under OCR 1557

Emergency Preparedness

• Staff training every two years
• Exercises twice a year
• EP policies and procedures
• Emergency plan

H&P Changes

• When is an H&P required
• Assessments instead in healthy outpatients
• Medical staff policy requirements
• Considerations

Look Back Program and the Lab

• Notification of tainted blood
• Patient notification process
• The time frame for notification

Nursing Services and Outpatient Departments

• Staffing-adequate number
• Supervisory staff
• Need to respond immediately when needed
• Nursing care plans
• Policies and procedures
• CNO must evaluate nursing staff including agency staff
• All outpatient departments must identify if RN must be present
• Outpatient policy required
• P&P must be reviewed by MEC
• Orders for drugs and biologicals
• Verbal orders

Autopsies

• Deleted requirement to get in unusual cases
• Coroner cases

Four swing bed changes

• Dental
• Activity program and assessment and plan of care
• Social worker
• Residents performing services

Infection Control and Antibiotic Stewardship

• Hospital-wide surveillance
• CDC outpatient assessment tools
• Following nationally recognized standards and best practices
• Infection control hospital-wide QAPI program
• Infection control program and policies requirements
• Qualified infection preventionist
• Requirements for the antibiotic stewardship program
• Antibiotic stewardship policies
• Tracking all infections
• QAPI leadership
• Competency-based staff training

Critical Access Hospital

• Summary of changes
• Infection Prevention and Control
• Staffing and credentialing
• QAPI

Who Should Attend?

• Pharmacist
• Chief nursing officer
• Health information manager
• Infection preventionist
• Antimicrobial stewardship team members
• Nurses
• Nurse educators
• Chief medical officer
• QAPI director and staff
• Patient safety officers
• Regulatory and compliance officers
• Physician assistants (PAs),  
• Patient advocate
• Risk management
• MEC chair
• Anyone involved in implementing the hospitals CoPs.