Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2020 Update

Did you know there were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) that went into effect on November 29, 2019? Did you know there were over eighteen CMS survey memos of importance to nursing in the recent past? The final changes were in the Hospital Improvement Rule. It will discuss plans of care, staffing, policy changes, when an RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement, and more.  

Did you know that CMS has issued deficiency reports which include which are the most problematic standards for hospitals? Did you know that nursing services have been cited over 5,635 times according to the most recent report? This is a must-attend program for any chief nursing officer, clinical nurse or nurse supervisor, or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. This must-attend program will discuss the deficiencies and how hospitals can ensure compliance.

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. If a surveyor showed up at your door tomorrow, would you be prepared?

CMS made changes to IV medication administration, blood transfusion, safe injection practices, compounding, beyond-use date (BUD), and implemented safe opioid standards. Hospitals are still struggling with how to comply with these complicated standards.

There are many changes in the past to this section including the timing of medications, standing orders, soft wrist restraints, and restraint reporting, plan of care, verbal orders, blood transfusions, IV medication, compounding, BUD, antibiotic stewardship program, safe injection practices, self-administration of medications and drug orders. CMS has issued the final worksheets on QAPI, discharge planning, and infection control which should be on the radar screen of all department managers. There are also proposed changes to the infection control worksheet which will be discussed. 

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, Health Care Facility Accreditation Program, CIHQ, and DNV GL Healthcare must also follow these regulations.

This program will also reference other important sections that all nurses should be aware of that are found outside the nursing services section such as the revised discharge planning standards, medication standards, revised history and physicals, visitation, restraint and seclusion, grievances, and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

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 is used. Staffing, medications, a three-time frame for administering medications, and educational requirements will be discussed along with changes in standing orders and protocols. CMS starting to issue deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.

• Recall that CMS has a section on nursing services that every hospital must follow even if accredited 
• Describe that all medications must be administered within three different time frames
• Discuss that nursing care plans are a frequently cited area by CMS 
• Recall that all verbal orders must be signed off and need to include both a date and time
• Recall that there is a focus on safe injection practices by CMS

• Introduction into the CMS hospital CoPs
• Where to locate a copy
• CMS deficiency reports and problematic standards
• How to keep apprised of changes
• Changes to medication management, IV, blood, and opioid safe use
• Final changes under the Hospital Improvement Rule to nursing
• ISMP IV push guidelines
• Safe injection practices
• Changes related to safe injection practices, compounding, medication preparation, immediate use, and labeling
• CMS Hospital worksheets and importance
• Recent CMS memos of interest
  • Hospital deficiencies
  • Safe injection practices
  • Legionnaire’s 
  • Reporting to the PI system
  • Insulin pens and safe injection practices
  • Organ Procurement Organization Contracts
  • Discharge planning standards (final November 29, 2019)
  • CMS complaint manual
  • Humidity in the OR
• CDC resources on preventing HAI
• Final interpretive guidelines and changes
• Most current CMS Manual  
• Starts at Tag 385 and goes to tag 413
• Nursing Services and 24 hours services
• 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
• A valid license for nurses and verification
• RN to evaluate the care of all patients
• Nursing care plans
• Changes to the plan of care
• Agency nurse requirements
• The orientation of agency nurses
• Medication administration
• The order required for all medications
• OCR Section 1557 
• Standards of care and practice to prevent HAI
• BUD, compounding sterile preparations (CSP)
  • Immediate use CSP
  • Administration one hour rule
• Safe injection practices
• 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
• History and physicals
• Discharge planning revised standards

• Chief Nursing Officer
• All Nurses
• Nurse Managers
• Nurse Supervisors
• Nurse Educators
• HIM Staff
• Compliance Officer
• Chief of Medical Staff
• Medical Staff Coordinator
• Risk Manager
• Patient Safety Officer
• Senior Leadership
• COO
• Documentation Specialist
• Hospital Legal Counsel
• QAPI Director
• Joint Commission Coordinator
• Regulatory Officers
• Legal Counsel
• Chief Operating Officer
• Chief Medical Officer
• Physicians
• Education Department Staff
• Board Members
• Director of Health Information Management
• Audit Staff
• Others responsible for Compliance with Hospital Nursing Regulations including Documentation Compliance

Please note that CMS has a separate CoP for critical access hospitals (CAHs). However, since the CAH nursing CoPs were rewritten on April 7, 2015, they are for the most part the same or a shorter version. These differences are discussed. Any CAH attending can have access to the CAH nursing CoPs because the tag numbers are different.