Radiology, Contracts, Emergency Services, Rehab, Visitation, Medical Records, Surgery, Anesthesia, QAPI, Organs, and Swing beds

At the conclusion of part three, participants should be able to:

• Explain the informed consent elements required by CMS,
• Describe the requirements for history and physicals for CAH,
• List what must be contained in the operative report,
• Discuss what the CAH must do to comply with the requirements for notification of the organ procurement (OPO) agency when a patient expires,
• Recall that CMS has many patient rights that are afforded to patients in swing beds.
• Recall that hospitals must have a visitation policy and patients must be informed 

Radiology

• Many  changes
• Radiology services
• Radiology staff
• Scope of radiology services
• Radiology policies required

Contracted Services

Emergency procedures

Visitation

• Written copy to patient and document
• Patient advocate
• When the patient is incapacitated
• P&P required
• Staff education required

Rehab section 

• Order
• Plan of care requirements

Medical Records

• Final changes 
• Timely access to medical records
• OCR now fining hospitals if access is not timely
• Medical record standards
• Identification of author
• Inpatient and outpatient requirements for medical records
• Records System
• Informed consent
• List of procedures required for consent
• Medical necessity and the RACs (recovery audit contractors)
• History and physicals
• Discharge summaries
• Preventing unnecessary readmissions
• Response to treatment
• Confidentiality of medical records
• Retention of medical records
• Protection of Record Information

Surgical Services

• Surgery policies required
• PACU
• OR register
• Operative report
• Surveyor in the OR
• Surgical privileges
• Designation of Qualified Practitioners

Anesthesia services

• Anesthetic Risk and Evaluation
• Administration of Anesthesia
• Pre-anesthesia evaluation
• Post-anesthesia evaluation
• Discharge
• PI required
• Healthcare-associated infections
• State Exemption of CRNAs
• Periodic Evaluation

Organ, Tissue, and Eye Procurement

• Definition of imminent death
• Tissue and eye bank
• Family notification
• Organ donation

Special Requirements for CAH Providers of Long-Term Care Services (Swing beds)

• Rewritten and four changes in 2020
• Eligibility
• Payment
• SNF Services
• Resident Rights
• Exercise of Rights
• Notice of Rights and Services
• Free Choice
• Privacy and Confidentiality
• Mail
• Access and Visitation Rights
• Personal Property
• Married Couples
• Admission, Transfer, and Discharge Rights
• Transfer and Discharge
• Payment of care
• Content of notice
• Resident Behavior and Facility Practices
• Restraints, Abuse 
• Staff Treatment of Residents
• Hiring of employees
• Activities 
• Social Services
• Dental requirements 
• Resident Assessment
• Comprehensive Care Plans
• Discharge Summary
• Nutrition
• Provision of Services
• Websites for CAH
• CAH resources