2018 CMS Hospital Improvement Rule Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
120 minutes
Product Description

Prepare for CMS’s Proposed Changes in 2018 to the Hospital Improvement Rule

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. All hospitals will be required to have an antibiotic stewardship program and the new changes will explain what the program should include. The changes will include a prohibition on discrimination that 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.

Join this session, where medico-legal consultant Sue Dill Calloway, RN, MSN, JD, will discuss the changes that CMS has proposed regarding the hospital conditions of participation (CoPs) that every hospital should know. The session will cover changes to patient rights and medical records, QAPI, nursing services and outpatient departments, and infection control and antibiotic stewardship.

Session Highlights

With this session, you will learn about:

  • The antimicrobial stewardship program that all hospitals will have to implement
  • CMS’s proposal to change LIP to licensed practitioner (LP) so PAs can order restraint and seclusion and do assessments
  • The policies, which every hospital must have, that describe which outpatient areas require a RN
  • The final diagnosis that would have to be in the medical record for all outpatients within 7 days

Session Outline

Patient rights and medical records

  • Restraint five changes
  • Change from LIP to 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
      • November 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
    • Information to monitor patient conditions


  • 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 whether 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

Who Should Attend

  • Pharmacists
  • Chief nursing officers
  • Health information management
  • Infection preventionists
  • Antimicrobial stewardship team members
  • Nurses
  • Nurse educators
  • Chief medical officers
  • QAPI staff
  • Patient safety officers
  • Regulatory and compliance officers
  • Physician assistants (PAs)
  • Patient advocates
  • Risk management
  • Nurse educators
  • Hospital legal counsel
  • MEC chairs
  • Board members
  • Anyone involved in implementing the hospitals CoPs
  • Anyone who is interested in the CMS 5-star rating system

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of...   More Info
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