Part 1: Introduction, CMS Survey Memos, Surveyor Training Material, Hospital Deficiency Reports, CMS 3 Worksheets, CDC Vaccine, OCR 1557, Required Education, Hard Hit Areas, Board and Medical Staff, Budget, Contracts, Emergency Services, Medical Records, Standing Orders, H&Ps - Thursday, Jan. 21
Part 2: Patient Rights: Advance Directives, Consent, Interpreters, Grievances, Exercise of Patient Rights, Disclosures, Privacy, Safety, Ligature Risks, Abuse and Neglect, Confidentiality, Restraints and Visitation - Thursday, Jan. 28
Part 3: Nursing and Pharmacy - Thursday, Feb. 4
Part 4: QAPI, Medical Staff, Dietary, Radiology, Lab, Utilization Review and Facility Services - Thursday, Feb. 11
Part 5: Infection Control, Discharge Planning, Organ, Surgery, PACU, Anesthesia, ED, Outpatient, Rehab, and Respiratory - Thursday, Feb. 18
All sessions 9 to 11 a.m., CST
Content
This five-part webinar series will cover the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) for acute care hospitals.
This program will cover the more than 500 pages of the State Operations Manual for acute care hospitals. Each section of the manual will be discussed including those which have had recent updates and still-pending Interpretive Guidelines.
The interpretive guidelines serve as the basis for determining hospital compliance and there have been significant changes and many important survey memos in recent years. CMS issued the final surveyor worksheets for assessing compliance with quality and performance improvement (QAPI), infection control and discharge planning standards. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance.
Speaker
Laura A. Dixon, B.S., J.D., RN, CPHRM
Laura A. Dixon served as the director, facility patient safety and risk management and operations, for COPIC, a medical liability insurance agency, from 2014 to 2020. In her role, Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of health care facilities and development of programs and compilation of reference materials that complement physician-oriented products.
Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services and pain management. Prior to joining COPIC, she served as the director, western region, patient safety and risk management, for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to physicians and staff for the western United States.
Who should attend
Anyone responsible for their organizations’ compliance with CMS regulations.
Continuing education
Each session in the webinar series has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 1 contact hour.
Learning objectives
Part 1:
- Discuss how to locate a copy of the current CMS CoP manual
- Describe that a history and physical for a patient undergoing an elective surgery must not be older than 30 days and updated the day of surgery
- Discuss that verbal orders must be signed off by the physician along with a date and TIME
Part 2:
- Recall that CMS has restraint standards that hospitals must follow
- Describe that the patient has a right to file a grievance and the hospital must have a grievance policy and procedure in place
- Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical record
- Discuss the patients’ rights regarding advanced directives
Part 3:
- Describe that medications must be given timely and within one of three blocks of time
- Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
- Recall that there are many pharmacy policies required by CMS
- Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
- Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy
Part 4:
- Recall that CMS has patient safety requirements in the QAPI section that are challenging standards
- Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified
- Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state
Part 5:
- Discuss that CMS requires many policies in the area of infection control
- Recall that patients who are referred to home health, Inpatient rehab, LTCH, and LTC must be given a list in writing of those available and this must be documented in the medical record
- Describe that all staff must be trained in the hospital’s policy on organ donation
- Recall that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment
- Recall that CMS has finalized the discharge planning worksheet and changes to the standards
Fee
- $200 per session for MHA member hospitals and health systems
- $300 per session per organization for nonmembers
In order to allow for social distancing, pricing is set up per hospital rather than per connection. Please register just one person from your facility and have that person share the access information with others within your facility who wish to participate. Each hospital within a system must register separately.
Registration deadline
Please register by 5 p.m. two business days before each session to ensure timely delivery of access instructions.
Approximately four business days before each session in the webinar series, you will receive an email that contains instructions on how to connect. Advance registration is required to ensure delivery of instructional materials.
If you do not receive an email from Christy Hammer prior to the program with web conference details, please contact info@mnhospitals.org to confirm your registration.