Emergency Services; Complying with the CMS Hospital CoPs

This webinar covers the hospital CoPs that affect the emergency department. These interpretive guidelines are located in two separate sections of the hospital CoP manual. Any hospital that accepts Medicare must follow the CMS CoPs and for all patients. This section discusses staffing requirements, provision of services both on and off-campus, EMTALA, required policies and procedures, training requirements, medical director requirements, and compliance with standards of care. It will also discuss the requirements for restraint and seclusion, grievances, and protocols. This program will help educate what hospital emergency departments need to do to prevent being out of compliance with the CMS hospital requirements.

Outpatient Services; Complying with the CMS Hospital CoPs and Proposed Changes

This webinar covers the hospital CoPs that affect the outpatient department. Any hospital that accepts Medicare must follow the CMS CoPs and for all patients. There have been several changes over the past several years. Hospitals must ensure the outpatient director is qualified and competent. There must be an order for the outpatient test and the board must approve this whether credentialed and privileged or not. The outpatient department must follow standards of care and practice and these will be discussed.

This program will also cover the final changes to the outpatient section. These were published in the Hospital Improvement Rule that went into effect on November 29, 2019. The hospital will be required to have a policy and designate which outpatient departments will require an RN. CMS feels that documentation in the outpatient area is often inadequate. There are additional changes that will be discussed.

This webinar will also discuss what deficiencies hospitals have been received in the outpatient area and why hospitals are being cited by CMS. CMS publishes quarterly deficiency data.

Objectives of Emergency Services; Complying with the CMS Hospital CoPs:-

• Recall that CMS has a section in the hospital CoP manual on emergency services
• Discuss that CMS requires the emergency department to have specified policies and procedures
• Describe that there are restraint and seclusion standards that staff must follow
• Explain what has required if the patient files a grievance

Objectives of Outpatient Services; Complying with the CMS Hospital CoPs and Proposed Changes:-

• Recall that CMS has a section in the hospital CoP manual on outpatient services
• Discuss that the outpatient department must follow standards of practices
• Describe that an order is needed for an outpatient test or procedure
• Recall that hospitals must have a policy and list of all the outpatient departments and which ones must be staffed with an RN

Detailed Outline of Emergency Services; Complying with the CMS Hospital CoPs:-

• Introduction
• Location of the manual
• Survey memos
• Access to complaint data
• EMTALA and 2019 changes
• Required policies
• Hospitals without emergency departments
• Staff training
• Transport policies
• On-campus and off-campus responsibilities
• Medical Staff and emergency procedures
• Meeting needs of patients
• Following standards of care
  • ACEP and ENA
• QAPI
• Lab, x-ray, medical records, surgery responsibilities
• Qualified medical director required
• Equipment and supplies
• Staffing
• Restraint and seclusion and November 29, 2019 change
• Grievance
• Protocols

Detailed Outline of Outpatient Services; Complying with the CMS Hospital CoPs and Proposed Changes:-

• Outpatient services must meet the needs of patients
• Final changes the effective date of November 29, 2019
• Following the acceptable standard of practice
• Compliance with all CMS CoPs
• Starts at tag number 1076
• Must be integrated with patient services: lab, radiology, medical record, etc.
• Written policies including communication to assure integration
• One or more person responsible for outpatient services
• Have appropriate personnel
• Written qualifications and competencies of director
• Adequate number of staff
• Orders of practitioner
• Orders of C&P and those not C&P
• Verification of licensure, OIG list of excluded individuals
• Ensure services and equipment is available

Who Should Attend Emergency Services; Complying with the CMS Hospital CoPs?

Emergency department physicians, nurses, mid-level providers (such as PA and NP) and staff, chief medical officer, chief nursing officer, compliance officer, patient safety officer, in-house legal counsel, risk managers, director of regulatory compliance, nurse supervisors, and anyone who is responsible to ensure compliance with the hospital conditions of participation.

Who Should Attend Outpatient Services; Complying with the CMS Hospital CoPs and Proposed Changes?

Outpatient department director, physicians, nurses, mid-level providers (such as PA and NP) and staff, chief medical officer, chief nursing officer, compliance officer, patient safety officer, in-house legal counsel, risk managers, director of regulatory compliance, nurse supervisors, and anyone who is responsible to ensure compliance with the hospital conditions of participation.