CMS Hospital Improvement Rule Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI & More

Product Id : HE136
Instructor : Sue Dill Calloway
Apr 29, 2019 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 90 Minutes

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CMS has proposed some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. This include 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 is proposing to add the current law requirements under OCR 1557 and place them into the CMS hospital CoPs. Also a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final.

This webinar by medical legal consultant, Sue Dill Calloway, RN, MSN, JD, will keep you updated and give you a better understanding on the existing, proposed and new requirements of the CMS Hospital Improvement Rule. It will touch upon important topics and areas such as nursing, medical records, infection control, the Antibiotic Stewardship Program, restraints and seclusions, QAPI and more.

Detailed Outline:

  • 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
  • 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
  • QAPI
    • Quality indicator data including patient care data
    • Medicare Quality Reporting Data
    • Hospital readmission data
    • Hospital acquired conditions (HACs) and 5 changes
    • QAPI leadership
  • Nursing Services and Outpatient Departments
    • Staffing and supervisory staff
    • Immediate response
    • Nursing care plans
    • Policies and procedures
    • Outpatient policy
    • Annual review of P&P
    • Orders for drugs and biologicals
    • Verbal orders
  • Infection Control and Antibiotic Stewardship
    • Hospital wide surveillance
    • Following nationally recognized standards and best practices
    • Infection control hospital wide QAPI program
    • Infection control program and policies requirements
    • Qualified infection preventionist
    • Tracking all infections
  • 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
  • Competency based staff training
  • OCR 2016 2 documents on access to medical records – A non-compliance area according to CMS
  • Non-discrimination under OCR 1557
  • Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries

Also Includes:

  • Live Q&A session with speaker
  • PPT and other handouts
  • Certificate of attendance

Who Will Benefit:

  • Pharmacist
  • Chief nursing officer
  • Health information manager
  • Infection preventionist
  • Antimicrobial Stewardship team members
  • Nurses and nurse educators
  • Chief medical officer
  • Regulatory and compliance officers
  • Patient advocate
  • Hospital legal counsel
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a 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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