PART ONE OF FOUR   Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

Objectives:-

At the conclusion of part one, participants should be able to:

• Describe that CMS requires that the board must enter into a written agreement if the hospital wants to enter into a  telemedicine contract
• Discuss that CMS has a list of emergency drugs and emergency equipment that every CAH must-have.
• Recall that the length of stay in the CAH should not exceed 96 hours on an annual average basis.
• Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.

Agenda:-

Introduction

• History
• Final changes: Discharge planning and the Hospital Improvement Rule
• Most recent changes
• CMS memos
• Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, texting, revised complaint manual, humidity in the OR, OPO contracts, equipment maintenance, EBOLA, CRE, ligature risks and scopes, glucose meters, etc
• ISMP IV Push Guidelines
• CAH problematic standards
• CAH Resources
• Conditions of participation
• CMS 3 Worksheets
• How to find manual, survey memos, and changes
• CMS websites
• Copies of documents by the surveyor
• How to locate changes
• Rehab or Psych distinct unit standards
• CMS Survey and Certification website
• Visitation
• Telemedicine standards

Survey Protocol

• Introduction
• Tasks in the Survey Protocol
• Survey Team

Regulations and Interpretive Guidelines for CAHs

• Swing bed module
• Compliance with Federal, State and Local Laws and Regulations
• Licensure of CAH
• Licensure, Certification or Registration of Personnel
• Status and Location
• Location Relative to Other Facilities or Necessary Provider Certification
• Compliance with CAH Requirements at the Time of Application Agreements
• Agreements with Network Hospitals
• Agreements for Credentialing and Quality
• Advanced directives
• Emergency Services, respiratory policies
• ED staffing
• EMTALA
• Equipment, Supplies, and Medication
• Blood and Blood Products
• Staffing/Personnel
• Coordination with Emergency Response Systems
• Number of Beds and Length of Stay
• Observation, the two-midnight rule
• Number of Beds
• Length of Stay