CMS Hospital Improvement Act Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI and much more!

Duration: 105 Minutes
CMS has proposed some significant changes to the hospital conditions of participation (CoPs) that every hospital should know including critical access hospitals. This includes changes to nursing, medical records, infection control, QAPI, patient rights and restraint and seclusion. It will also require all hospitals to have an antibiotic stewardship program and what the program should include. It will include a prohibition on discrimination which must be given to patients in writing.
CMS Hospital Improvement Act,
Instructor: Sue Dill Calloway
Product ID: 508562
Objectives of the Presentation
  • Recall that hospitals will have to implement an antimicrobial stewardship program
  • Discuss that CMS proposes to change LIP to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments
  • Describe that the hospital must have policies that describe which outpatient areas require a RN
  • Recall that a final diagnosis would have to be in the medical record for all outpatients within 7 days
Why Should you Attend
Attend this training program to know what are the CMS proposed changes to the hospital conditions of participation (CoPs) that every hospital should be aware of.

Areas Covered
Patient Rights and Medical Records
  • Restraint five changes
  • Change from LIP to licensed practitioner (LP)
  • Physician Assistants (PAs) to order and evaluate
  • Right to access medical records
    • Oral or written request
  • OCR 2016 2 documents
  • Non-discrimination
    • Written policy prohibiting
    • Inform each patient on prohibition against discrimination
    • Inform on how to file a complaint
  • Medical Records
    • Content of medical records
    • Document complications and hospital acquired conditions
    • Diagnosis in outpatient record in 7 days
    • Final diagnosis
    • Discharge instructions and transfer summaries
      • Will also discuss Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
    • Information to monitor patient conditions
QAPI
  • Quality indicator data including patient care data
  • Medicare Quality Reporting Data
  • Hospital readmission data
  • Hospital acquired conditions (HACs) and 5 changes
Nursing Services and Outpatient Departments
  • 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
  • Annual review of P&P
  • Orders for drugs and biologicals
  • Verbal orders
Infection Control and Antibiotic Stewardship
  • Hospital wide surveillance
  • Following national 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
    • Qualified leader who must be appointed by the board
    • Active program and evidenced based use of antibiotics
    • Document improvements and reduction of CDI
    • Board responsibilities
    • Responsibilities of leader of antibiotic stewardship program
  • Antibiotic stewardship policies
  • Tracking all infections
  • QAPI leadership
  • Competency based staff training
Who will Benefit
Pharmacist, chief nursing officer, health information management, infection preventionist, antimicrobial stewardship team members, nurses, nurse educators, chief medical officer, QAPI staff, patient safety officers, regulatory and compliance officers, physician assistants (PAs), patient advocate, risk management, nurse educators, hospital legal counsel, MEC chair, board members and anyone involved in implementing the hospitals CoPs. Anyone who is interested in the CMS 5-star rating system should also attend.
$375
Recorded Session for one participant
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  • Presentation handouts in downloadable PDF format will be updated on your OCP Account within 24 hours of the purchase of the product
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  • Please share your valuable Feedback at the end of the session
Instructor Profile:
Sue is president of Patient Safety and Healthcare Consulting and Education company with focus on medical legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.
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