CMS Hospital Conditions of Participation 2022 Surgery PACU and Anesthesia Standards

This program will cover the CMS hospital CoP standards for surgery, anesthesia, and PACU. Every hospital that accepts Medicare and Medicaid must follow these standards and they must be followed for all patients.

In addition to covering the Conditions of Participation requirements for Surgery, Anesthesia, and PACU, this program will cover some of the important CMS memos that discuss safe injection practices and infection control breaches with IV medications, changes to history, and physical requirements for healthy outpatients, and consent requirements for procedures. Surgical privileges, PACU standards, and standards for the delivery of anesthesia are also covered.

Some of the important CMS memos that impact the provision of care in the OR arena and discuss safe injection practices and infection control breaches with IV medications will be discussed. Guidance from ISMP and CDC will also be provided.

Hospitals are required to have many policies including one on specific clinical situations involving anesthesia or analgesia. This includes interpretive guidelines on moderate sedation and deep sedation, including moderate and deep sedation done in other places like the emergency department and GI lab and patients who have ECTs.

• Recall that there are several policies and procedures required by CMS related to surgery and anesthesia services
• Describe that CMS has a section that addresses PACU requirements
• Recall that CMS has a list of things that must be included in the OR register
• Describe what information is required for informed consent and that it should be on the chart before surgery
• Discuss the 48-hour requirements for the post-anesthesia evaluation of both inpatients and outpatients

Surgery AND PACU:-

• CMS manual and website
•  CMS Certification and Survey Memos
  • Humidity in the OR
  • Safe injection practices
  • Infection control breaches memo
  • CMS worksheets with a section on safe injection practices
• Deficiency reports for Surgery, PACU, and Anesthesia
• Surgical services chapter
• Infection control in ORs
• Equipment, temperature, humidity
• Supervision in the OR
• Scrub tech and circulators
• Surgical privileges
• Surgery policies required
• Preventing OR fires and wrong site/side surgeries
• History and physical 2019 & 2020 changes    
• Informed consent and what must be included
• OR Register
• Operative report requirements
• Surgery equipment required
• PACU standards
  • Monitoring of patients receiving opioids

Anesthesia:-

• Director of Anesthesia Services
• Anesthesia versus analgesia
• General, regional, MAC, topical, minimal sedation, moderate sedation
• Rescue capacity
• Other locations in the hospital where anesthesia is provided
• QAPI
• Director of Anesthesia responsibilities 
• Those who can administer anesthesia
• Scope of practice for CRNA and Anesthesia Assistants
• CRNA state exemption
• Anesthesia Policies required
• Pre-anesthesia assessment
• Post-anesthesia evaluations
• Consent and safety policies required
• Documentation requirements
• Intraoperative anesthesia record requirements

• CEOs
• COOs
• CFOs
• Nurse Executives (CNO)
• Accreditation and Regulation Director
• Nurse Managers
• Pharmacists
• Pharmacist Compliance Officers
• Health information management
• Nurses
• Nurse Educators
• Nursing Supervisors
• Quality Managers
• Risk Managers
• Healthcare Attorneys
• Patient safety officer
• Infection preventionist
• Radiology director
• Emergency Department Directors
• Outpatient Director
• Medication Team
• Ethicist
• Director of Rehab: OT, PT, speech pathology, and audiology
• CRNA
• Anesthesia providers
• Radiology staff
• QAPI staff
• Policy and Procedure Committee
• Infection Control Committee Members