Nursing: CMS CoP Standards for Hospitals and Proposed Changes- 2021 Update

There were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020 and it is anticipated there will be additional changes in 2021. In late 2020, CMS made changes to the section in response to the COVID-19 pandemic for “hospital at home” facilities.  There have been over eighteen CMS survey memos of importance issued relating to nursing in the recent past. The final changes were in the Hospital Improvement Rule. This program 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. 

CMS has issued deficiency reports which include which are the most problematic standards for hospitals. The nursing services have been cited over 6,300 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.

CMS made previous revisions to IV medication administration, blood transfusion, safe injection practices, compounding, beyond-use date (BUD), and implemented safe opioid standards. Hospitals continue to struggle with how to comply with these complicated standards, especially the safe opioid interpretive guidelines.

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 also issued the final worksheets on QAPI, discharge planning, and infection control which should be on the radar screen of all department managers, especially because there were changes in 2020 in all these sections and with interpretive guidelines and survey procedure still to be decided by CMS. There are also proposed changes to the infection control worksheet which will be discussed.  All of these sections, components of patient care are impacted to some degree by nursing.  That is why it is so important for you to attend this program.

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.

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

• Introduction into the CMS hospital CoPs
• General information on CMS including online access and email contact for CMS to ask questions
• CMS deficiency reports and problematic standards
• 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 medication 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
  • CMS complaint manual
  • Humidity in the OR
• CDC resources on preventing healthcare-acquired infections (HAI)
• Nursing Services and 24 hours services
• RN on duty – recent update
• Integrated with hospital-wide PI program
• Organizational chart and nursing
• Chief Nursing Officer (CNO) responsibilities & 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 and 2020 changes
• Standards of care and practice to prevent HAI
• BUD, compounding sterile preparations (CSP)
  • Immediate use
  • Administration one hour rule
• Safe injection practices
• Standing orders and protocols
• Three medications timing changes
• Protocols, standing orders, order sets
• Requirements for complete drug order
• Verbal orders
• Verbal orders changes
• Blood transfusions and IV medications changes
• Self-administered medications
• 1135 Waivers for sections addressed

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, and 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, and in 2020, they are for the most part the same or a shortened version. These differences are discussed. Any CAH attending can have access to the CAH nursing CoPs because the tag numbers are different. All of the CAH tag numbers changes in 2020.