Agenda Discovery Week Month

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CMS Hospital Improvement FINAL Rules- Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, Q

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Endorsed by Curators:
Jan 30 1:00PM - 4:00PM

CMS has 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.

Most have an effective date of November 29, 2019, with two exceptions. The normal implementation date is 60 days but Critical Access Hospitals will have 6 months to implement an antibiotic stewardship program and 18 months to implement a QAPI program since their QAPI requirements were completely written.

It will also require all hospitals to have an antibiotic stewardship program and what the program should include. Also, a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.

Session Outline:-


Interpretive guidelines and survey procedure to be issuedHow to get a copy of the CoP manual, survey memos, etc.Why revise the CoPs

Psychiatric Hospitals

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

Emergency Preparedness

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

H&P Changes

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

Patient Rights and Medical Records

Restraint changes
Change from LIP to the licensed practitioner (LP)
Physician Assistants (PAs) to order and evaluate
Non-discrimination under OCR 1557
Written policy prohibiting
Inform each patient on the prohibition against discrimination
Inform on how to file a complaint
Currently, already law and CMS decides NOT to include in the CoPs
Medical Records section was not implemented
Content of medical records
Document complications and hospital-acquired conditions
Diagnosis in the outpatient record in 7 days
Discharge instructions and transfer summaries


Quality indicator data including patient care data
Medicare Quality Reporting Data
Hospital readmission data
Hospital acquired conditions (HACs) and 5 changes

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

Look Back Program and the Lab

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


Deleted requirement to get in unusual cases
Coroner cases

Four swing bed changes

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
The qualified leader who must be appointed by the board
Active program and evidenced-based use of antibiotics
Document improvements and reduction of CDI
Board responsibilities
Responsibilities of the leader of the antibiotic stewardship program
Antibiotic stewardship policies
Tracking all infections
QAPI leadership
Competency-based staff training


Recall that hospitals have requirements in the CMS CoPs on an 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 an RN
Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths

Who Should Attend?

Chief Nursing Officer
Health Information Management
Infection Preventionist
Antimicrobial Stewardship Team Members
Nurse Educators
Chief Medical Officer
QAPI Director and Staff
Patient Safety Officers
Regulatory and Compliance Officers
Physician Assistants (PAs)
Patient Advocate
Risk Management
Hospital Legal Counsel
MEC Chair
Board Members
Anyone involved in Implementing the Hospitals' CoPs

Upcoming Events

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Endorsed by Curators:
The CMS Hospital Infection Control Worksheet and Final Changes and Antibiotic Stewardship Program

The CMS Hospital Infection Control Worksheet and Final Changes and Antibiotic Stewardship Program

Jan 20 1:00PM - 3:00PM
Description:-If there is one webinar your hospital should listen to this year it should be this one. If a surveyor showed up at your door tomorrow would your hospital be prepared? The worksheet is…
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Endorsed by Curators:
Safe Injection Practices and IV Push Guidelines- Compliance with CMS and CDC Safe Injection Standards

Safe Injection Practices and IV Push Guidelines- Compliance with CMS and CDC Safe Injection Standards

Jan 23 1:00PM - 3:00PM
Description:-Every hospital or ambulatory surgery center that accepts Medicare or Medicaid reimbursement should listen to this important program! Imagine a CMS (Center for Medicare and Medicaid…
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Endorsed by Curators:
CMS Hospital CoP UR Planning Standards 2020

CMS Hospital CoP UR Planning Standards 2020

Jan 29 1:00PM - 4:00PM
Description:-This program will cover the CMS (Center for Medicare and Medicaid Services) hospital Conditions of Participation regulations for Utilization Review. Every hospital that accepts Medicare…