Nursing CMS CoP Standards for Hospitals

Hospitals receiving Medicare and Medicaid reimbursements must comply with the stringent Conditions of Participation (CoPs) set forth by the Centers for Medicare & Medicaid Services (CMS). These regulations are essential for all patients within the hospital and extend to facilities with Deemed Status accredited by organizations such as the Joint Commission, HFAP, CIHQ, and DNV Healthcare. Despite the critical importance of these regulations, many institutions struggle with adherence, particularly in the nursing services section of the CoP manual. The most recent updates to the hospital nursing chapter have introduced changes that remain pending interpretive guidelines and survey procedures, leading to widespread confusion and compliance challenges.

Join industry expert Laura A. Dixon, BS, JD, RN, CPHRM, for an insightful webinar that demystifies the nursing services section of the CoP manual. This session is designed to provide healthcare professionals with a clear understanding of the often-cited areas of nursing care, including:

• Plans of Care: How to develop and maintain effective plans of care that meet CoP standards.
• Staffing Requirements: Ensuring adequate staffing levels and understanding when a Registered Nurse is required in outpatient departments.
• Policy Changes: Staying abreast of recent policy updates and their impact on nursing services.
• Documentation: Best practices for maintaining thorough and compliant documentation.
• Supervision and Leadership: Understanding the roles and responsibilities of nursing leaders.
• Verbal Orders: Proper procedures for issuing and documenting verbal orders.

The webinar will also cover significant past changes in the Nursing section, including updates on:

• Timing of medications
• Standing orders
• Blood transfusions
• IV medication administration
• Self-administration of medications
• Drug orders

Additionally, the session will address the evolving non-discrimination regulations under Section 1557 and other relevant sections of the manual that impact nursing practices.

By attending this webinar, you will gain practical insights and strategies to ensure your facility's nursing services are fully compliant with CMS CoPs, reducing the risk of citations and enhancing the quality of patient care.

Webinar Objectives

• Understanding CMS Nursing Services Requirements: Gain a comprehensive understanding of the nursing services section mandated by CMS, applicable to all hospitals, including those with accreditation.
• Medication Administration Timeframes: Learn about the three critical timeframes for administering medications, ensuring compliance with CMS guidelines.
• Nursing Care Plans: Explore why nursing care plans are frequently cited by CMS and how to develop compliant and effective care plans.
• Verbal Order Requirements: Recall and understand the specific requirements for issuing and documenting verbal orders in accordance with CMS regulations.

Webinar Agenda

• Introduction into the CMS hospital CoPs manual
• CMS deficiency reports
• 2020 changes to Nursing section
• Recent memos affecting nursing
  • Ligature risks
  • Discharge Planning
• Non-Discrimination and Nursing
• Conditions of Participation - Nursing
• Nursing Services and 24-hour services
• RN on duty – recent update
• Organizational chart and nursing
• Chief Nursing Officer (CNO) responsibilities & requirements
• Staffing and delivery of care
• 24-hour nursing services and supervision
• RN to evaluate to care of all patients
• Nursing care plans
• Changes to the plan of care
• Assignment of patient care
• Agency nurse requirements
• Outpatient departments
• Medication administration
• Order required for all medications
• Requirements for complete drug order
• Medication safety and “5 Rights”
• Safe Injection practices
• Three medications timing changes
• Safe Opioid use
• Standing orders and protocols
• Verbal orders
• Blood transfusions and IV medications changes
• Reporting blood administration and medication errors
• Home and Self-administered medications
• CAH Nursing requirements
• Other manual section of importance to Nursing
  • Restraint and seclusion
  • Medication policies
  • Visitation
  • Discharge planning revised standards

Webinar Highlights

• Comprehensive review of the CoP manual’s nursing services section
• Guidance on recent updates and pending changes
• Practical solutions for common compliance issues
• Enhanced understanding of non-discrimination regulations
• Expert tips for effective documentation and policy implementation

Who Should Attend

• Chief nursing officer
• All nurses
• Nurse managers/supervisors
• Nurse educators
• Compliance officer
• Chief of medical staff
• Risk manager
• Patient Safety officer
• Senior leadership
• Joint Commission coordinator
• Regulatory officers
• Physicians