Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.

This program will reference other important sections that all nurses should be aware that are found outside the nursing services section such as medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, discharge planning standards and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols. CMS starting issuing deficiency reports and this will be covered so hospitals are aware of which are the problematic tag numbers.

Agenda topics:

• CMS deficiency reports
• Changes to medication management
• Revised CMS Hospital work sheets
• ISMP IV push guidelines
• Recent CMS memos of interest
• Federal regulation changes
• Changes to 9 tag numbers
• Staffing and delivery of care
• CNO requirements
• BUD and CSP
• Verbal orders    

After this webinar participants will be able to:

1. Recall that CMS has a section on nursing services that every hospital must follow even if accredited.
2. Describe that all medications must be administered within three different time frames.
3. Discuss that nursing care plans are a frequently cited area by CMS and recall a recent change.
4. Recall that all verbal orders must be signed off and need to include both a date and time.
5. Recall that there is a focus on safe injection practices by CMS.

Target Audience:

Chief nursing officer, all nurses, nurse managers, nurse supervisors, nurse educator, HIM staff, compliance officer, chief of medical staff, medical staff coordinator, risk manager, patient safety officer, senior leadership, documentation specialist, hospital legal counsel, PI director, Joint Commission coordinator, regulatory officers, legal counsel, chief operating officer, physicians, education department staff, board members, director of health information management, audit staff, and others responsible for compliance with hospital regulations including documentation compliance.