Achieving Compliance in the Face of New CoP Guidelines and Standards for Hospitals
CMS issued deficiency reports in the recent past have revealed that CMS CoP has been a problematic standard for many hospitals. Not less than 15 memos of importance have been issued and many changes have occurred in the past two years in the nursing section—including 2016 changes and proposed changes for 2017 in the Hospital Improvement Act. Do you know that CMS has issued deficiency reports which includes which are the most problematic standards for hospitals?
It is mandatory for every hospital to have a copy of CMS's up-to-date Conditions of Participation (CoPs) along with Interpretive Guidelines (IG). Keeping the manual handy is necessary as they are used by surveyors to guide inspections and follow laid down guidelines for ensuring full reimbursement. This manual includes details for CMS Survey Protocol Guidelines, comprising a set of questions that surveyors ask during an on-site visit.
Hospitals, including critical access hospitals (CAHs), must be informed and updated about these four critical areas of CMS CoP standards for hospitals:
The CoP Dietary, CAH Dietary, DNV Healthcare and TJC Standards —CMS made 3 changes to the dietary guidelines for hospitals and rewrote all the dietary guidelines for critical access hospitals.
The CMS Final Infection Control Worksheet— Many hospitals have not heard about it and are not aware of what they need to do to prepare should a surveyor coming knocking at their door.
2017 CMS Nursing CoP Standards for Hospitals and Proposed Changes —The proposed changes aims to deal with the most problematic standards for hospitals as revealed by the CMS’ deficiency reports.
New CMS CoP Regulations for Managing Grievances and Complaints – The third most common problematic standards for hospitals.
On January 9, 2017, CMS issued its final rule, which sheds light on Medicare and Medicaid CoPs for home health agencies. This rule subsequently came into effect on January 13, 2017. The last update for CoPs before this occurred roughly two decades ago. Post this announcement; hospitals are regularly required to review the ongoing CoPs to ensure continued compliance with the Medicare and Medicaid standards. Hospital facilities which are unable to match these standards risk losing their credibility. Failure to comply with the CoPs can stop Medicare from making payment to the hospital. It can also lead to violation of the False Claims Act, leading to stringent sanctions from governing bodies.
Updating your organization/facility/hospital with the latest CMS CoP standards is critical for compliance; avoiding violations, massive fines and enforcement actions; and of course, protecting your bottom line.
Why should you attend?
The CMS CoPs Virtual Boot Camp has been designed to provide hospitals with practical, straightforward insights and explanations on the standards and gives you actionable plans to ensure compliance. By attending this information-packed event, you will learn how you can work towards building a strong foundation of CMS CoP compliance in your healthcare organization.
Session 1: 2017 CMS Nursing CoP Standards for Hospitals and Proposed Changes
Length: 90 Minutes
Significant changes were made by CMS to blood transfusion, compounding, safe injection practices, IV medication administration, beyond use date (BUD) and implemented safe opioid standards. Many changes to the final interpretive guidelines went into effect in the past two years. The final worksheets on QAPI, discharge planning and infection control, which should be on the radar screen of every department managers, has been issued by the CMS.
This session by expert speaker Sue Dill Calloway, RN, MSN, JD, is a must attend for any clinical nurse or nurse leader or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations. It will also discuss staffing, medications, three time frame for administering medications and educational requirements, along with changes in standing orders and protocols, and will cover the CMS’ issue of deficiency reports so hospitals are aware of which are the problematic tag numbers.
Review CMS’ section on nursing services that every hospital must follow even if accredited
Know how all medications must be administered within three different time frames
Discuss recent changes in nursing care plans and why it is a frequently cited area by CMS
Why all verbal orders must be signed off and need to include both a date and time
Session 2: The CMS Final Infection Control Worksheet for Hospitals
Length: 90 Minutes
The surveyor worksheet for the assessment of compliance with the infection control Conditions of Participation (CoPs) has been finalized by the CMS. These worksheets are used by state and federal surveyors on all survey processes when assessing compliance with the infection control standards. With the new changes, hospitals should now also develop tracer tools to match this worksheet. Hospitals may also face similar questions from accreditation organizations to get deemed status from CMS.
Attend this webinar by expert speaker Sue Dill Calloway, RN, MSN, JD, and stay prepared for any visit by a surveyor, who might show up at your door any time for a validation survey. Sue will help you get a better understanding of the CMS hospital infection control worksheet. This session will also discuss the infection control deficiencies published by the CMS along with actual information on why hospitals were found to be out of compliance.
Review the 49-page final hospital infection control worksheet
Infection preventionist identified and qualified
Identify infection control program and resources
Discuss required infection control policies for hospitals
Guidance on following nationally recognized standards (CDC, APIC, etc.)
Training program and identification of must include problems
Discuss that the infection control worksheet has a tracer on indwelling urinary catheters
Describe what CMS requires for safe injection practices and sharps safety
Discuss that the infection control worksheet has a section on hand hygiene tracer
Best practices for physicians, nurses and other healthcare professionals
Review the deficiency reports issued by the CMS in this area
Session 3: New CMS CoP Regulations for Managing Grievances and Complaints
Length: 90 Minutes
CMS has issued that their first memo summarizing non-compliance and grievances were a top problematic standard. A report issued by CMS on January 28, 2016 found as many as 773 hospitals out of compliance. Join Sue Dill Calloway, RN, MSN, JD, in this informative session to learn what you need to do to ensure compliance. This program will cover the CMS requirements in detail for hospitals to help prevent them from being found out of compliance in regards to the grievance regulations.
Sue will also take up TJC standards on complaints and DNV Healthcare on grievances, and just how these crosswalk to CMS grievance interpretive guidelines. This session will cover what is now needed to be documented in the medical records. It will also include discussion on the AHRQ proposed consumer reporting system for patient safety events and in what way this could impact the area of complaints and grievances.
Find out why any hospital that receives reimbursement for Medicare patients must follow the CMS CoPs on grievances. (This is true whether the hospital is accredited by Joint Commission, AOA, CIHQ, DNV Healthcare or not).
Learn that the CMS regulations under grievances include the requirement to have a grievance committee.
Learn that the Joint Commission has complaint standards in the patient’s right (RI) chapter and DNV grievance standard in the patient rights chapter.
Know that in most cases the patient must be provided with a written notice that includes steps taken to investigate the grievance, the results, and the date of completion.
The required process for the review of certain denials of access
Insights on why AHRQ is proposing a consumer reporting system for patient safety events.
The final changes from CMS about the hospital CoPs are somewhat complex and confusing. In the final rule, CMS has made 3 changes to the existing dietary guidelines for hospitals and has rewritten all the critical access hospitals dietary guidelines. As per the new rule, the CMS will now allow the Medical Staff and Board to credential and privilege qualified dieticians and qualified nutritional specialist to order the patient’s diet. This will include therapeutic diet, supplemental feeding and enteral nutrition.
In this session, Sue Dill Calloway, RN, MSN, JD, will help you learn about the new regulations, and discuss the CMS hospital conditions of participation requirements for dietary and food and nutrition services. Sue will also discuss the Joint Commission provision of care chapter standards related to dietary and the TJC dietary tracer information. This event will provide insights on the DNV Healthcare dietary standards.
CMS Food and Dietetic Services CoP Topics
TJC Provision of Care Standards related to Dietary
Topics Discussed Throughout the Patient Tracer Activity
Dietary and food services day to day operation information
Sue Dill Calloway, RN, MSN, JD, is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. Sue was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.