CMS Hospital Improvement Rule Proposed Changes

Recorded Webinar | Virginia Pesata | From: Jun 24, 2019 - To: Jun 28, 2019

CMS has proposed some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. This includes 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. Also a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.

Agenda topics:-

  • Right to access medical records
  • Quality indicator data
  • Annual review of P&P
  • Antibiotic stewardship
  • Content of medical records
  • Nursing care plans
  • Infection control

After this webinar participants will be able to:-

  • 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 a RN.
  • Recall that a final diagnosis would have to be in the medical record for all outpatients within 7 days.

Target Audience:-

Anyone who is interested in the CMS 5-star rating system and involved in implementing hospital CoPs, including but not limited to: 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.

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