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CMS 2018 Hospital Improvement Rule 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 on access to medical records
- Non-discrimination under OCR 1557
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 national 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. CMS is proposing to add the current law requirements under OCR 1557 and place them into the CMS hospital CoPs.
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 Officials
- Nurse educators
- Hospital legal counsel
- MEC chair
- Board members
- Anyone involved in implementing the hospitals CoPs
- Anyone who is interested in the CMS 5-star rating system should also attend
Why should you attend?
One of the main changes CMS is planning to make this year is with regards to the Antibiotic Stewardship Program as today only 68% hospitals have them in place. As observed by the office of civil rights, the need for interpreters at hospitals has also risen due to increased number of patients with limited English proficiency. OCR has found that 1 in 10 HIPAA complaints surround the patient access to medical records. This has been noted by the CMS in their proposed rules and they have made necessary provisions for patients in order to have better access to medical records.
There have been many examples where the CMS has observed that hospitals and providers have not been following the right protocol. As a result, they have proposed numerous changes that impact outpatient services, Nursing services, nursing plans of care, medical records and more. In addition to this, CMS also found inadequate documentation in outpatient care. The Proposed changes from CMS on the COP’s apply to all hospitals including critical access hospitals. This includes changes to nursing, patient rights, QAPI, infection control, medical records, restraint and seclusion. It will require all hospitals to have an antibiotic stewardship program that includes prohibition on discrimination. This must be given to patients in writing. This session by expert speaker, Sue Dill Calloway, RN, MSN, JD, discusses the above amendments and changes in detail.
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.