CMS Hospital Improvement FINAL Rules

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CMS Hospital Improvement FINAL Rules
Nursing, Medical Records, Infection
Control Antibiotic Stewardship Program,
Restraints, QAPI, and more
Speaker - Laura A. Dixon
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About Speaker
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 management topics,
assessment of healthcare facilities and
development of programs and compilation of
reference materials that complement
physician-oriented products. Ms. Dixon has more
than twenty years of clinical experience in acute
care facilities, including critical care,
coronary care, peri-operative services, and pain
management. Prior to joining COPIC, she served as
the Director, Western Region, Patient Safety and
Risk Management for The Doctors Company, Napa,
California. In this capacity, she provided
patient safety and risk management consultation
to the physicians and staff for the western
United States. Ms. Dixons legal experience
includes representation of clients for Social
Security Disability Insurance providing legal
counsel and representation at disability hearings
and appeals, medical malpractice defense, and
representation of nurses before the Colorado
Board of Nursing. As a registered nurse and
attorney, Laura holds a Bachelor of Science
degree from Regis University, RECEP of Denver, a
Doctor of Jurisprudence degree from Drake
University College of Law, Des Moines, Iowa, and
a Registered Nurse Diploma from Saint Lukes
School Professional Nursing, Cedar Rapids, Iowa.
She is licensed to practice law in Colorado and
California.
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Description
CMS finalized some significant changes to the
hospital conditions of participation (CoPs) that
every hospital should know, including critical
access hospitals. It was 393 pages long and
combined three laws into one. This includes
changes to nursing, medical records, infection
control, QAPI, patient rights, HPs, and
restraint and seclusion.  The effective date was
November 29, 2019.   The new rule requires all
hospitals to have an antibiotic stewardship
program and what the program should include among
other requirements. A great part of this document
included care issues that CMS has found to be
problematic in hospitals that are already a
requirement within the Conditions of
Participation.
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Learning Objectives

• Recall that hospitals have requirements in the
  CMS CoPs on antimicrobial stewardship program
• Discuss that CMS change the term LIP (licensed
  independent practitioner) to LP (licensed
  practitioner) so PAs can order restraint and
  seclusion and do assessments if allowed by the
  hospital
• Describe that the hospital must have policies
  that describe which outpatient areas require an
  RN
• Recall CMS removed the section that required
  hospitals to conduct autopsies in cases of
  unusual deaths

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Session Outline

• Nursing Services and Outpatient Departments
• Autopsies
• Four swing bed changes
• Infection Control and Antibiotic Stewardship
• Critical Access Hospital

• Overview of the changes
• QAPI
• Psychiatric Hospitals
• Patient Rights and Medical Records
• Emergency Preparedness
• HP Changes
• Look Back Program and the Lab

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Who Should Attend

• Pharmacist
• Chief nursing officer
• Health information manager
• Infection prevention
• Antimicrobial stewardship team members
• Nurses
• Nurse educators
• Chief medical officer
• QAPI director and staff

• Physician assistants (PAs)
• Patient advocate
• Risk management
• MEC chair
• Anyone involved in implementing the hospital's
  CoPs
• Patient safety officers
• Regulatory and compliance officers

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To Learn More
Register Now