CMS Hospital Improvement Rules Nursing, History and Physicals, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI, and more

CMS made some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. Changes include nursing, history and physicals, infection control, QAPI, and orders for restraint and seclusion. The effective date was November 29, 2019. However Critical Access Hospitals had until the end of March 2021 to implement a QAPI program since their QAPI requirements were completely written.

The new rules require all hospitals to have an antibiotic stewardship program and what the program should include. The CDC revised the core elements in November of 2021. A great part of the Rule included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified several existing requirements and several federal regulations that are already final which makes this webinar an excellent resource.

• Recall that hospitals have requirements in the CMS CoPs on an antimicrobial stewardship program
• Discuss CMS changes 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
• Discuss the changes for the CAH QAPI program

Introduction

• Interpretive guidelines and survey procedures to be issued
• How to get a copy of the CoP manual, survey memos, etc.

Acute Hospitals

• Restraints & seclusion
• Who can write orders

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

QAPI

• Quality indicator data including patient care data
• Medicare Quality Reporting Data
• Hospital readmission data

H&P Changes

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

Nursing Services

• 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

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
• A qualified leader who must be appointed by the board
• Active program and evidence-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

Four swing bed changes

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

CAH Changes

• Emergency Preparedness
• Infection Prevention and Control and ASP
• QAPI

Miscellaneous Changes

• Non-discrimination under OCR 1557
• Autopsies

Three Worksheets

Appendix and Resources

• Chief Nursing Officer
• Pharmacist
• Health information management
• 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)
• Risk management
• MEC chair
• Board members
• Anyone involved in implementing the hospital's CoPs