Webinar ID: # 1019
Recorded Webinar @ All Day
Duration: 90 minutes
Description:
The Centers for Medicare and Medicaid Services (CMS) is crucial in healthcare. One of its primary functions is to issue final rules and regulations that govern various aspects of healthcare delivery in hospitals. These final rules aim to improve patient care and ensure patient safety during hospital stays.
CMS finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This includes changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. The effective date was November 29, 2019.
The new rule requires all hospitals to have an antibiotic stewardship program and what the program should include, among other requirements. A significant part of this document included care issues that CMS found problematic in hospitals that are already a requirement within the Conditions of Participation. CMS also clarified some existing requirements and many federal regulations that are already final, which makes this webinar an excellent resource.
Webinar Highlights:
- Hospitals will need to review and implement the requirements.
- Implement an antibiotic stewardship program to reduce inappropriate antibiotic use and resistance.
- Implement P&P to prevent and report unsafe patient care practices, medical errors, and adverse events.
- Hospitals have requirements in the CMS CoPs on antimicrobial stewardship programs.
- Understanding to get a copy of the CoP manual, survey memos, etc.
- Learning the changes from LIP to the licensed practitioner (LP).
- Non-discrimination under OCR 1557 policy for hospitals to maintain a healthy environment.
- Following nationally recognized standards and best practices for Infection Control and Antibiotic Stewardship.
- Emergency preparedness plans must be reviewed and updated every two years.
- All outpatient departments must identify if an RN must be present.
- To secure autopsies for unusual deaths and medical-legal and educational interest cases.
- CDC Guide to Infection Prevention for Outpatient Settings.
- Emphasizes the critical role of pharmacists and nurses in improving antibiotic use.
- AHA, Office of Rural Health, and Pew Charitable Trusts developed practical strategies to implement ASP.
Areas covered:
Introduction
- Overview of the changes
- How do I get a copy of the CoP manual, survey memos, etc?
- Why revise the CoPs
QAPI
- Quality indicator data, including patient care data
- Medicare Quality Reporting Data
- Hospital readmission data
- Hospital-acquired conditions (HACs) with five changes
Psychiatric Hospitals
- Non-physicians writing in-progress notes
- How often progress notes must be written
Patient Rights and Medical Records
- Restraint changes
- Change from LIP to licensed practitioner (LP)
- Physician Assistants (PAs) to order and evaluate
- Non-discrimination under OCR 1557
Emergency Preparedness
- Staff training every two years
- Exercises twice a year
- EP policies and procedures
- Emergency plan
H&P Changes
- When is a H&P required
- Assessments instead in healthy outpatients
- Medical staff policy requirements
- Considerations
Look Back Program and the Lab
- Notification of tainted blood
- Patient notification process
- The time frame for notification
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 RNs must be present
- Outpatient policy required
- MEC must review P&P
- Orders for drugs and biologicals
- Verbal orders
Autopsies
- Deleted requirement to get in unusual cases
- Coroner cases
Four swing bed changes
- Dental
- Activity program and assessment and plan of care
- Social worker
- Residents performing services
Infection Control and Antibiotic Stewardship
- Hospital-wide surveillance
- CDC outpatient assessment tools
- 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
- Antibiotic stewardship policies
- Tracking all infections
- QAPI leadership
- Competency-based staff training
Critical Access Hospital
- Summary of changes
- Infection Prevention and Control
- Staffing and credentialing
- QAPI
Why Should You Attend:
CMS hospital improvement final rules are at the forefront of ensuring quality care and safety in hospitals. The guidelines regarding nursing standards, medical records, infection control, and other areas are paramount in shaping the healthcare landscape. The goal is to provide better, safer healthcare for patients, and it is a goal that continues to evolve and adapt to the changing needs of patients and the healthcare systems.
Who Should Attend:
- Pharmacist
- Chief nursing officer
- Health information manager
- Infection prevention
- Antimicrobial stewardship team members
- Nurses
- Nurse educators
- Chief medical officer
- QAPI director and staff
- Patient safety officers
- Regulatory and compliance officers
- Physician assistants (PAs),
- Patient advocate
- Risk management
- MEC chair
Presenter Information:
Name: Laura A. Dixon
Short Bio:Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners, and staff in multiple states.
Such services included the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.
Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director of, Western Region, Patient Safety, and Risk Management for The Doctors Company, Napa, California.
In this capacity, she provided patient safety and risk management consultation to the physicians and staff in the western United States. Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense, and representation of nurses before the Colorado Board of Nursing.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.