CMS Hospital Nursing CoP Standards 2014

Duration: 90 Minutes
Instructor: Sue Dill Calloway
Webinar Id: 800251


One Attendee


Did you know there are new changes to nine of the tag numbers in the nursing service chapter? Did you know there were ten recent memos of importance to nurse managers and chief nursing officers? There are many changes to this section in the recent past including timing of medications, standing orders, restraint, plan of care, verbal orders, blood transfusions, IV medication, third revised worksheet, and drug orders. CMS made over two dozen changes to the hospital CoP regulations effective July 16, 2012.

There are many changes to the final interpretive guidelines effective June 7, 2013 and August 30, 2013 with a new CoP hospital manual being issued August 30, 2013. In fact, there were two new tag numbers added to the nursing standards section and changes to seven existing sections including tags 405-409 and 410 through 413. 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 program will cover the nursing services section in the hospital CoP manual.

Facilities accredited by the Joint Commission, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations. Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don't be caught off guard and put your hospital's reimbursement at risk. This program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality.

CMS issues the privacy and confidentiality memo, safe injection practices memo and insulin pen memo. This program will include what is in the CMS discharge planning worksheet. It will include tips to prevent unnecessary readmissions. 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, new three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols.

Areas Covered in the Session:

  • Introduction into the CMS hospital CoPs
  • Where to locate a copy
  • How to get apprised of changes
  • Revised CMS Hospital work sheets and importance
  • Recent CMS memos of interest
    • Rewrote all the discharge planning standards
    • Hospital deficiencies
    • Reporting to the PI system
    • Insulin pens and safe injection practices
    • New interpretive guidelines
    • Luer misconnections
    • Discharge planning standards
    • CMS complaint manual
  • OPO contract
  • Hospital complaint manual and reported to AO memo
  • Humidity memo
  • Interpretive guidelines effective June 7, 2013 and August 30, 2013
  • New Manual issued
  • Many recent changes to 9 tag numbers
  • Starts at Tag 385 and goes to tag 413
  • Nursing Services and 24 hours services
  • Third revised worksheet
  • Social Security Administration Act  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
  • Valid license for nurses and verification
  • RN to evaluate to care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • Orientation of agency nurses
  • Medication administration
  • Order required for all medications
  • Standing orders and protocols
  • Three medications timing changes
  • Protocols, standing orders, order sets
    • Tag 405 standards moved to 457
  • Requirements for complete drug order
  • Verbal orders
  • Verbal orders changes
  • Blood transfusions and IV medications changes
  • Self administered medications
Other important sections nurses should be aware of:
  • Restraint and seclusion changes
  • Grievances
  • Medications policies
  • Visitation

Who Will Benefit:
  • Chief nursing officer (CNO)
  • Nurse Managers
  • HIM Staff
  • Compliance Officer
  • Chief of Medical Staff
  • Medical Staff Coordinator
  • Risk Manager
  • Patient Safety Officer
  • Regulatory Officers
  • Legal Counsel
  • Chief Risk Officer
  • Audit Staff

Speaker Profile
Sue Dill Calloway R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She also does a monthly series on the sections of the Conditions for Coverage for Ambulatory Surgery Centers along with other ASC programs such as Safe Injection Practices. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over fifteen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.

She has been employed in the nursing profession for more than 30 years. Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals. She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers. Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus. She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.

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