The CMS Hospital Conditions of Participation

This five-part webinar series will cover the entire CMS Hospital CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual, especially ones that apply to their department. Hospitals have seen a significant increase in survey activity by CMS. This program will discuss the most problematic standards. The program will cover how the hospital can do a gap analysis to assist in compliance with the CoPs.

Part 1

• Discuss how to locate a copy of the current CMS CoP manual
• Describe that a history and physical for a patient undergoing an elective surgery must not be older than 30 days and updated the day of surgery
• Discuss that verbal orders must be signed off by the physician along with a date and TIME
• Describe the changes to medical record requirements, including interoperability and “blocking”

Part 2

• Recall that CMS has restraint standards that hospitals must follow
• Describe that a hospital must have a grievance policy and procedure in place
• Recall that interpreters should be provided for patients with limited English proficiency and hearing impairment
• Describe how non-physician practitioners – PA, NPs – can order restraints

Part 3

• Describe which medications must be given timely and within one of three blocks of time
• Recall that all order/protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
• Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
• Discuss patient safety issues with compounding pharmacies
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Part 4

• Recall the requirement for and elements of a QAPI program
• Describe the need for radiology policies, including one on radiation safety and the need for qualified staff
• Discuss the new option of credentialing the dietician to order diets – if allowed by the state
• Describe the need for facility maintenance program to include water management

Part 5

• Discuss that CMS requires many policies in infection prevention and control
• Recall that patients referred a post-acute care provider – PAC – must be given a list in writing of those available and this must be documented in the medical record
• Describe that all staff must be trained in the hospital’s policy on organ donation
• Recall that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment

Target Audience

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality managers, nurse educators, risk managers, compliance officers, chief of health information, pharmacists, social workers, discharge planners, patient safety officers, outpatient director, director of rehab, infection control, directors of radiology.

Faculty

Lena Browning, MHA, RNC-NIC, CSHA, Consultant, Nash Healthcare Consulting
Lena Browning is a nurse leader and accreditation specialist with more than twenty-five years of experience in clinical leadership in acute care settings. Throughout her career, she has demonstrated a commitment to improving patient safety by empowering staff and leadership to maintain continuous compliance and achieve excellence in patient care across healthcare settings.

As a Principal Consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled 3 Interim positions as Director of Accreditation and was responsible for restructuring accreditation departments and leading organizations in continuous compliance and preparation for survey readiness for their triennial Joint Commission (TJC) or Centers for Medicare and Medicaid Services (CMS) survey. Since then, those three organizations have had successful surveys with no condition-level findings. She is a true pioneer in leadership development and coaching for excellence in healthcare accreditation.

Sharon Courage, RN, BSN, MPH Senior Consultant, Nash Healthcare Consulting
Sharon Courage is a Registered Nurse with a Master’s in Public Health. Ms. Courage has thirty years of experience in hospital quality and risk management, quality improvement, development of hospital programs, patient safety, and acute and long-term care.

From 2002 until the present, Ms. Courage served hospitals nationwide in developing programs and system improvements in patient safety, quality and risk management, infection control, program assessment, and accreditation preparation. She has assisted with the development and implementation of regulatory plans of correction, process development and implementation as well as process design for automation and electronic medical record documentation simplification. She also assisted hospitals with assessment and strategy development and implementation to meet Joint Commission and CMS compliance including the development of sustainable strategies following conditional CMS survey findings.

Continuing Education

April 6, 13, 20, 27 and May 4, 2022

This educational activity is jointly provided by AXIS Medical Education and Texas Hospital Association

ACCREDITED CONTINUING EDUCATION
Accreditation Statement

[logo goes here] In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for  2.0 contact hours each.

Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

AXIS Contact Information
For information about the accreditation of this program please contact AXIS at [email protected].

Disclosure of Conflicts of Interest
AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity.

AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty, Lena Browning, MHA, RNC-NIC, CSHA, and Sharon Courage, MPH, RN reported no relevant financial relationships or relationships with ineligible companies of any amount during the past 24 months.

The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:

• Attend/participate in the educational activity and review all course materials.
• Complete the CE Declaration form online by 11:59 pm ET June 4, 2022. Instructions will be provided at the conclusion of each Webinar. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation.
• Upon successful completion of the online form, your statement of completion will be presented to you to print.