Nursing: CMS CoP Standards for Hospitals and Proposed Changes: 2022 Update

Laura A. Dixon

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk...
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90 Mins
Laura A. Dixon

There were multiple changes to the hospital nursing chapter of the conditions of participation (CoPs) in 2020. However, many of those changes are still awaiting interpretive guidelines and survey procedures.  In late 2020, CMS made changes to the section in response to the COVID-19 pandemic for “hospital at home” facilities.

This webinar will discuss plans of care, staffing, policy changes, when an RN is required in an outpatient department, documentation, supervision, nursing leadership, verbal orders, antibiotic stewardship program requirement, and more.

CMS has issued deficiency reports which include which are the most problematic standards for hospitals. The nursing services have been cited over 6,300 times according to the most recent report. This is a must-attend program for any chief nursing officer, clinical nurse or nurse supervisor, or person interested in ensuring compliance with the CMS hospital conditions of participation in nursing. This must-attend program and will discuss the deficiencies and how hospitals can ensure compliance.

There are many changes in the past to this section include timing of medications, standing orders, soft wrist restraints, and restraint reporting, plan of care, verbal orders, blood transfusions, IV medication, compounding, BUD, antibiotic stewardship program, safe injection practices, self-administration of medications and drug orders.

Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV Healthcare must also follow these regulations.

This webinar will also reference other important sections that all nurses should be aware of that are found outside the nursing services section such as the revised discharge planning standards, medication standards, revised history and physicals, visitation, restraint and seclusion, and grievances, and privacy and confidentiality. CMS issued the privacy and confidentiality memo, safe injection practices memo, humidity memo, and insulin pen memo.

Webinar Objectives

  • Recall that CMS has a section on nursing services that every hospital must follow even if accredited 
  • Describe the three different timeframes for which all medications must be administered 
  • Discuss that nursing care plans are a frequently cited area by CMS 
  • Recall that verbal orders must be signed off and must include both a date and time

Webinar Agenda

  • Introduction into the CMS hospital CoPs
  • General information on CMS including online access and email contact for CMS to ask questions
  • CMS deficiency reports and problematic standards
  • Changes to medication management, IV, blood, and opioid safe use
  • Final changes under the Hospital Improvement Rule to nursing        
  • ISMP safe injection practices
  • CMS memos of interest
    • Legionnaire’s 
    • Reporting to the PI system
    • Humidity in the OR
  • CDC resources on preventing healthcare-acquired infections (HAI)
  • Nursing Services and 24 hours services
  • RN on duty – recent update 
  • Integrated with hospital-wide PI program
  • Organizational chart and nursing
  • Chief Nursing Officer (CNO) responsibilities & requirements
  • CNO approval of nursing policies
  • Staffing and delivery of care
  • 24-hour nursing services and supervision
  • RN to evaluate to the care of all patients
  • Nursing care plans
  • Changes to the plan of care
  • Agency nurse requirements
  • Medication administration
  • Order required for all medications
  • OCR Section 1557 and 2020 changes
  • BUD, compounding sterile preparations (CSP)
  • Standing orders and protocols
  • Three medications timing changes
  • Protocols, standing orders, order sets
  • Requirements for complete drug order
  • Verbal orders
  • Blood transfusions and IV medications changes
  • Self-administered medications
  • 1135 Waivers for sections addressed

Other important sections nurses should be aware of:

  • Restraint and seclusion changes
  • Grievances
  • Medication policies
  • Visitation
  • History and physicals
  • Discharge planning revised standards

Who Should Attend

  • Chief nursing officer
  • All nurses
  • Nurse managers/supervisors
  • Nurse educators
  • HIM staff
  • Compliance officer
  • Chief of medical staff
  • Medical staff coordinator
  • Risk manager
  • Patient safety officer
  • Senior leadership
  • COO
  • Hospital legal counsel
  • QAPI director
  • Joint Commission coordinator
  • Regulatory officers
  • Physicians
  • Education department staff
  • Board members
  • Director of health information management
  • Audit staff
  • Others responsible for compliance with hospital nursing regulations including documentation compliance.
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