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CMS Hospital Improvement Act Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI
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
- OCR 2016 2 documents
- Non-discrimination
-Written policy prohibiting
-Inform each patient on prohibition against discrimination
-Inform on how to file a complaint
- 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
*Will also discuss Nov 3, 2015, FR on proposed discharge planning standards related to discharge instructions and transfer summaries
-Information to monitor patient conditions
QAPI
- Quality indicator data including patient care data
- Medicare Quality Reporting Data
- Hospital readmission data
- Hospital-acquired conditions (HACs) and 5 changes
Nursing Services and Outpatient Departments
- Staffing-adequate number
- Supervisory staff
- Need to respond immediately when needed
- Nursing care plans
- Policies and procedures
- CNO must evaluate nursing staff including agency staff
- All outpatient departments must identify if RN must be present
- Outpatient policy required
- P&P must be reviewed by MEC
- 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
- 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
- Tracking all infections
- QAPI leadership
- Competency-based staff training
Overview of the webinar
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.
This session by expert speaker, Sue Dill Calloway discusses the proposed changes to the CMS Hospital Improvement Act, including infection control, the Antibiotic Stewardship Program, QAPI.
Who should attend?
- Pharmacist
- Chief Nursing Officer
- Health Information Management
- Infection Preventionist
- Antimicrobial Stewardship Team Members
- Nurses
- Nurse Educators
- Chief Medical Officer
- QAPI Staff
- Patient Safety Officers
- Regulatory and Compliance Officers
- Physician Assistants (PAs)
- Patient Advocate
- Risk Management
- Nurse Educators
- Hospital Legal Counsel
- MEC chair
- Board Members
- Anyone involved in implementing the hospital's CoPs
Why should you attend?
- Recall that hospitals will have to implement an antimicrobial stewardship program
- Discuss that CMS proposes to change LIP to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments
- Describe that the hospital must have policies that describe which outpatient areas require an RN
- Recall that a final diagnosis would have to be in the medical record for all outpatients within 7 days
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.