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Ensure compliance with the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) regarding hospital nursing services. Join our webinar as we delve into critical areas of the CoP manual, addressing plans of care, staffing, policy changes, and more. Benefit from expert insights and guidance to navigate the complexities of hospital nursing services compliance. Don't miss opportunity to enhance understanding, ensure regulatory compliance in nursing care. Register Now, https://conferencepanel.com/conference/nursing-standards-cms-condition-of-participation-for-hospitals
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HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2024 Nursing Sections Acute and Critical Access Hospitals Presented By: Laura A. Dixon, BS, JD, RN, CPHRM Healthcare Risk Education & Consulting, LLC
Speaker •Laura A. Dixon, Esq. • BS, JD, RN, CPHRM • President, Healthcare Risk Education, and Consulting, LLC • 303-955-8104 • Email questions to CMS: Critical Access Hospitals: qsog_CAH@cms.hhs.gov. Acute hospitals: qsog_hospital@cms.hhs.gov. 2 2
2020 Changes to Nursing Sections Hospital Improvement Rule
Nursing Section Changes • Clarified: • • • Need nursing supervisor Sufficient staff Immediate availability of RN at the bedside to respond when needed • • • • Must have current nursing care plan Must have evidence of reassessment and include patient goals and treatment preferences All nurses, not just agency nurses, must follow P&Ps CNO must evaluate all clinical activities of nurses • Including agency nurses and other staff • Need an order for drugs • Except flu and pneumovax when you have a protocol • • Verbal orders are to be used infrequently Must have P&P prohibiting discrimination • Cannot discriminate against race, color, national origin, disability, etc. • Not in CoP but OCR 1557 requirement • Must inform patient • In writing • In a language they can understand • Of right to be free from discrimination • Must inform the patient
CMS Memos and Nursing Section
6 Areas of Concern • Areas of concern on missing or inaccurate information: • 1. Medications • 2. DMEs • 3. Skin conditions (tears) • 4. Communications with PACs/caregivers on needs at home • 5. Patients with serious mental illness, SUDs, complex behavior needs • 6. Preferences and goals for care
Non-Discrimination and Interpreters Section 1557 and Nursing
Nursing Conditions of Participation Tag Nos. 385 – 413
Critical Access Hospitals Provisions of Services Nursing Tag Nos. C 1046 - 1050
Nursing Service and Leadership • Nursing service must be well-organized • Need designated person responsible for nursing services • Responsible for development of nursing P&Ps • Expected to be an RN • Title: CNO, DNO, Nurse manager
Content of Medication Order • Dose, frequency and route • Dose calculation requirements (if applicable) • Quantity and/or duration (when applicable) • Name of prescriber • Patient name • Age and weight – dose calculation • Date and time of order • Drug name • Exact strength or concentration (when applicable)
Nursing Care Plan • Plan develops appropriate nursing interventions based on identified needs • Must be part of the permanent medical record • Nursing can do as part of the interdisciplinary POC • BUT -must still do a nursing plan of care • Surveyor will check to make sure POC started soon after admission • Will also make sure it is revised as necessary
Manual Sections That Impact Nursing Outside Nursing Standards
The End Questions??? •Laura A. Dixon, Esq. • BS, JD, RN, CPHRM • President, Healthcare Risk Education, and Consulting, LLC • 303-955-8104 • ldesq@comcast.net Register Now
