The CMS Hospital Conditions of Participation (CoPs) Made Easy 2020

Description

If a CMS surveyor showed up in your hospital tomorrow, would you be prepared? 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 applies 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.

This program will also include the 600 pages of final changes in 2020. This includes the final discharge planning standards and the Hospital Improvement Rule. This includes changes to history and physicals, system wide QAPI and infection control, autopsy, discharge planning, infection control, antibiotic stewardship, medical records, nursing, outpatient, the role of non-physicians in psychiatric hospitals and more. The ligature risk and prevention of suicide will be covered which is a hot area of compliance.

Part 1 of 5 :-  August 4, 2020 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes - Pre-Recorded Session

Introduction, CMS Survey Memos, Surveyor Training Material, Hospital deficiency reports, CMS 3 worksheets, CDC Vaccine, OCR 1557, Required Education, Hard Hit Areas, Board and Medical Staff, Budget, Contracts, Emergency Services, Medical Records, Standing Orders, H&Ps

Learning Objectives:

• 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

Part 2 of 5 :- August 11, 2020 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes - Pre-Recorded Session

Patient Rights: Advance Directives, Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, Restraints and Visitation.

Learning Objectives:

• Recall that CMS has restraint standards that hospitals must follow
• Describe that the patient has a right to file a grievance and the hospital must have a grievance policy and procedure in place
  
• Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical record
  
• Discuss that the term LIP (licensed independent practitioner) has been changed to LP (licensed practitioner) to allow PAs to order restraints

Part 3 of 5 :- August 18, 2020 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes - Pre-Recorded Session

Nursing and Pharmacy

Learning Objectives:

• Describe that medications must be given timely and within one of three blocks of time
• Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
  
• Recall that there are many pharmacy policies required by CMS
  
• Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
  
• Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy

Part 4 of 5 :- October 20, 2020 | 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

QAPI, Medical Staff, Dietary, Radiology, Lab, UR, and Facility Services

Learning Objectives:

• Recall that CMS has patient safety requirements in the QAPI section that are problematic standards
• Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified
  
• Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state

Part 5 of 5 :- October 27, 2020 | 10:00 AM ET | 09:00 AM CT | 07:00 AM PT | 100 Minutes 

Infection Control, Discharge Planning, Organ, Surgery, PACU, Anaesthesia, ED, Outpatient, Rehab, and Respiratory

Learning Objectives:

• Discuss that CMS requires many policies in the area of infection control
• Recall that patients who are referred to home health, Inpatient rehab, LTCH, and LTC 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
  
• Understand that CMS has specific things that are required be documented in the medical record regarding the post-anaesthesia assessment
  
• Recall that CMS has finalized the discharge planning worksheet and changes to the standards

Who Should Attend?

• Chief Nursing Officer
• Chief Medical Officer
• Quality Managers
• Compliance Officers
• Nurse Educators, All Nurses
• Risk Managers
• Hospital Legal Counsel
• Joint Commission Liaison and Joint Commission Coordinator
• Discharge Planners
• PI Coordinator
• Patient Safety Officer, Patient Safety Committee,
• Medication Management Team,
• Anaesthesia and Surgery staff,
• PACU Director
• Policy and Procedures Committee
• Respiratory Therapy Director
• Director of Radiology
• Infection Preventionist
• Pharmacist and Pharmacy Director