Session 1: Nursing: CMS CoP Standards for Hospitals
Live Date: October 03, 2024
Time: 1 PM ET
Speaker: Laura A. Dixon
Duration: 90 minutes
Webinar Description
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. This webinar will cover the nursing services section in the hospital CoP manual. Facilities with Deemed Status accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.
There were some changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020. However, many of those changes are still awaiting interpretive guidelines and survey procedures.
This webinar will discuss the often-cited areas of the CoP manual involving nursing care: plans of care, staffing, policy changes, when a RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, and more. Nursing services has been cited over 8,900 times according to the most recent report.
Other changes in the past to the Nursing section include timing of medications, standing orders, plan of care, verbal orders, blood transfusions, IV medication, self-administration of medications and drug orders.
This webinar will also reference the ever-changing non-discrimination regulations of Section 1557, and briefly mention other sections of the manual that impact Nursing and for which nurses should be aware.
Webinar Objectives
- Recall that CMS has a section on nursing services that every hospital must follow even if accredited
- Describe the three different timeframes for which all medications must be administered
- Discuss that nursing care plans are a frequently cited area by CMS
- Recall the requirements for verbal orders
Webinar Agenda
- Introduction into the CMS hospital CoPs manual
- CMS deficiency reports
- 2020 changes to Nursing section
- Recent memos affecting nursing
- Ligature risks
- Discharge Planning
- Non-Discrimination and Nursing
- Conditions of Participation - Nursing
- Nursing Services and 24-hour services
- RN on duty – recent update
- Organizational chart and nursing
- Chief Nursing Officer (CNO) responsibilities & requirements
- Staffing and delivery of care
- 24-hour nursing services and supervision
- RN to evaluate to care of all patients
- Nursing care plans
- Changes to the plan of care
- Assignment of patient care
- Agency nurse requirements
- Outpatient departments
- Medication administration
- Order required for all medications
- Requirements for complete drug order
- Medication safety and “5 Rights”
- Safe Injection practices
- Three medications timing changes
- Safe Opioid use
- Standing orders and protocols
- Verbal orders
- Blood transfusions and IV medications changes
- Reporting blood administration and medication errors
- Home and Self-administered medications
- CAH Nursing requirements
- Other manual section of importance to Nursing
- Restraint and seclusion
- Medication policies
- Visitation
- Discharge planning revised standards
Session 2: Discharge Planning: Compliance with CMS Hospital & CAH CoPs in 2024
Live Date: October 24, 2024
Time: 1 PM ET
Speaker: Laura A. Dixon
Duration: 90 minutes
Webinar Description
Every hospital that accepts Medicare and Medicaid must adhere to the CMS discharge planning guidelines. These standards apply to all patients, not just those covered by Medicare or Medicaid. CMS mandates specific discharge planning policies and procedures, and this webinar will outline which ones are required and the reasons behind CMS's updates to these standards.
This session by industry expert Laura A. Dixon, will cover the Impact Act and its influence on hospital discharge planning, including standardized assessment, quality data, and resource data requirements. Hospitals are required to assist patients with post-discharge care options such as home health services, skilled nursing facilities, long-term care hospitals, and inpatient rehabilitation facilities, providing information on all four except for Critical Access Hospitals (CAHs).
Patients are entitled to timely access to their medical records, which must include details of the discharge planning process, discharge instructions, and discharge planning requirements. This webinar will also address the following topics:
- Transfers to other facilities
- Assessment of readmission within 30 days
- Caregiver rights and recommendations
- Reduction of factors leading to preventable readmissions
- Timely discharge planning
Additionally, the discharge planning conditions of participation for Critical Access Hospitals will be briefly discussed, highlighting their alignment with the requirements for acute care hospitals.
Webinar Objectives
- Discuss the revised discharge planning requirements by CMS for all hospitals and critical access hospitals.
- Recall how patients and physicians can request a discharge planning evaluation.
- Discuss the importance of providing hospitalization information to the physician or provider before the first post-hospital visit.
- Describe the patient’s right to timely access their medical records, including a copy of their discharge plan.
Webinar Agenda
- Introduction
- Deficiency data for discharge planning
- Discharge planning process and the IMPACT Act
- Identification of patients needing discharge planning
- Role of support person
- Incapacitated patient
- Discharge planning process
- RN, social worker, or qualified person to develop evaluation
- Timely evaluation
- Discussion of evaluation with patient or individual acting on their behalf
- Discharge evaluation in the medical record
- Documentation of the discharge process
- Discharge plan
- Physician request for discharge planning
- Implementation of the patient’s discharge plan
- Reassessment of the discharge plan
- Freedom of choice for post-acute care providers
- Transfer or referral
- Critical Access Hospital Discharge planning requirements
- Discharge planning metrics
- Appendix and Resources
Session 3: CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards
Live Date: November 14, 2024
Time: 1 PM ET
Speaker: Laura A. Dixon
Duration: 90 minutes
Webinar Description
Restraint and Seclusion is a hot spot with both CMS and the Joint Commission and an area where hospitals are frequently cited non-compliance. This webinar will discuss this most problematic standard.
CMS has fifty pages of interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients will have to comply with the regulations even if accredited by Joint Commission, HFAP, CIHQ, or DNV Healthcare.
Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis. CMS also says that restraint training must occur before a staff member/provider can apply or remove restraints and must be on-going so it cannot occur at orientation only. There are ten pages of training requirements.
Finally, this webinar will briefly cover The Joint Commission standards on restraint and seclusion, many which fall closely with the CMS Conditions of Participation.
Webinar Objectives
- Recall that CMS requires that all physicians and others who order restraints be educated on the hospital policy.
- Describe that CMS has restraint education requirements for staff.
- Discuss that CMS has specific things that need to be documented in the medical record for the one-hour face to face evaluation on patients who are violent and or self-destructive.
- Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with having two soft wrist restraints on.
Webinar Agenda
- Restraints in the news
- Introduction to CoP Manual
- Deficiencies – restraints and seclusion
- Complaint manual and process
- Conditions of Participation
- Seclusion – what it is and is not
- Medical restraints
- Behavioral health restraints
- Definition of restraint and seclusion
- Reasons to restrain
- Leadership responsibilities
- Falls and use of restraints
- Drugs used as a restraint
- What restraints do not include
- Side rails, forensic restraints, freedom splints, immobilizers
- Patient assessment
- Need order ASAP
- Order from LP and notification to attending physician
- Documentation requirements
- Least restrictive requirements
- RNs and One-hour face to face assessment
- Training for RN doing one-hour face to face assessment
- Training requirements
- Ending at earliest time
- Revisions to the plan of care
- Time limited orders
- Renewing orders
- Provider training
- Staff education
- First aid training required
- Monitoring of patient in R/S
- Death reporting requirements
- Joint Commission standards
Who Should Attend
- All nurses with direct patient care
- Compliance officer
- Chief nursing officer
- Chief of medical staff
- COO
- Nurse Educator
- ED nurses
- ED physicians
- Medical staff coordinator
- Risk manager
- Patient safety officer
- Chief Risk Officer
- PI director
- Joint Commission coordinator
- Nurse managers
- Quality director
- Chief medical officer
- Security guards
- Accreditation and regulation staff and others responsible for compliance with hospital regulations
- Anyone involved in the restraint or seclusion of patients.
- Any staff that could remove/apply restraints as part of care
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