Would you be prepared if a CMS surveyor showed up at your hospital tomorrow? Did you know that about a third of the CMS critical access manual was rewritten effective April 7, 2015? It was also updated October 9, 2015, October 14, 2016, December 1, 2016 and December 16, 2016. This includes rewriting the section on nursing, drugs and biologicals, pharmacy, dietary, infection control, lab, radiology, contracted services and adding the rehab section, IV medication, safe opioid use and blood eligibility to be a CAH, and addition of a CNS availability for on call to respond to the emergency department. This four part program will include information on the entire manual. This program will also discuss the proposed changes in 2017 in the Hospital Improvement Act and in the discharge planning standards. This includes the requirements to have an antibiotic stewardship program.
CAHs hospitals must comply with the Centers for Medicare & Medicaid Services’ CoP for Critical Access Hospitals. The CMS regulations and interpretive guidelines serve as the basis for determining compliance and this manual will be discussed in detail as well as the revised changes. Attendees will learn details about the CoPs and what to do when a surveyor arrives at your facility. Every section of the CAH hospital manual will be covered in this three part webinar.
CMS has issued many important hospital memos including privacy and confidential which is especially important in light of the HIPAA and the substantial penalties seen recently. Other memos include humidity in the OR, Effects of Humidity, CRE and scopes, insulin pens, safe injection practices, reporting to the PI program, complaint manual update, OPO contracts, EBOLA, telemedicine and EMTALA, equipment and maintenance, disaster preparedness and deficiencies for CAHs.
CMS received a $50 million dollar grant a number of years ago to enforce infection control standards and some hospitals are reporting increased scrutiny of these standards since surveyors are more knowledgeable. While CMS is not using the infection control worksheet at CAHs this program at this time, the webinar will discuss why it is important to be aware of what is in this worksheet and to use this as a self-assessment tool. There is also a final and revised worksheet on discharge planning and QAPI.
This seminar will help CAHs comply with specific CoP problem areas, including nursing care plans, legibility requirements, necessary policies and procedures, nursing medication carts, drug storage, informed consent, history and physicals, verbal orders, medication administration, security of medications, protocols, standing orders and emergency preparedness. There are many pharmacy standards and medication-related sections that will be covered in detail. Every tag section in the regulations and interpretive guidelines also will be covered. Attendees will learn details about the CoPs and what to do when a surveyor from arrives at your facility.