CMS Hospital Improvement Rules 2022 - Nursing, Antibiotic Stewardship Program and more


Webinar Details

Speaker

Laura A Dixon

Industry

Healthcare

Speciality

Nurse

Calendar

From: Apr 07, 2022 - To: Dec 31, 2022

Duration

120 Minutes

Registration Options

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Description

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.

Learning Objectives

  • 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

Agenda

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

Who Should Attend

  • 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
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense, and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.