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CMS CAH Cops 2017: Ensuring Compliance Part 2/4
Regulations and Interpretive Guidelines for CAHs
- Direct Services
- Services Provided through Agreements or Arrangements
- Nursing Services
- Drug and biologicals
- Security of medication
- Qualifications of pharmacy director
- Proper environmental conditions
- P&P to monitor all carts
- Compounding
- Blue box advisories
- Drug Quality and Security Act
- Standards of care
- Dispensing medications
- List of high alert medications
- Labeling
- Definition of medication error
- Adverse event
- Indicator or trigger drugs
Pharmacy
- Rewritten in 2015
- Inspections/staff interviews
- Dispensing of drugs
- Pharmacist responsibilities
- Staffing in pharmacy
- Pharmacy policies and procedures
- Medication therapy monitoring
- Pharmacy USP 797 regulations
- Emergency medicine kits
- Drug storage
- Nursing med carts/anesthesia carts
- Outdated drugs
- Survey of pharmacy
- Reporting ADR and medication errors
- Near misses/good catches
- High alert medication
- Definition of medication error required
- Trigger/indicator drugs
- Monitoring medication errors
- Medication alerts
- Standard of care for medications
- Websites and additional resources
- Required pharmacy P&P
- Do not use abbreviations
- Sound alike/look alike drugs
- Non-punitive policies
Dietary and Nutrition Services
- Rewritten in 2015
- Dietary policies
- C&P to order diet
- Meeting patient needs, diet order, follow recognized dietary practices
- Dietary compliance
- Qualified dietician
- Dietary support staff
- Assessment of patients and order
Overview of the webinar
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.
Who should attend?
- CEOs
- COOs
- CFOs
- Nurse Executives
- Accreditation and Regulation Director
- Nurse Managers
- Pharmacists
- Quality Managers
- Risk Managers
- Healthcare Attorneys
- Health Information Management Personnel
- Social Workers
- Dieticians
- Health Information Management
- Nurses
- Nurse Educators
- Nursing Supervisors
- Patient Safety Officer
- Infection Preventionist
- Radiology Director
- Emergency Department Directors
- Outpatient Director
- Medication Team
- Ethicist
- Director of Rehab (OT, PT, Speech Pathology and Audiology)
- CRNA
- Anesthesia Providers
- Dietician
- Radiology Staff
- Director of Health Information Management
- Infection Preventionist
- Activities director of Swing Bed Patients
- Infection Control Committee Members
- Pharmacists
- Compliance Officers
Why should you attend?
At the conclusion of part two, participants should be able to:
- Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy
- Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use
- Recall the requirements for security and storage of medications, medication carts and anesthesia carts
- Discuss the requirement to have a list of do not use abbreviations and a review of sound alike/look alike drugs
Faculty - Ms.Sue Dill Calloway
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. 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 worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications.
Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other healthcare providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.