Monitoring and Enforcement of CMS Hospital Improvement FINAL Rules

1
CMS Hospital Improvement Rules
2
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_at_cms.hhs.gov. Acute
  hospitals qsog_hospital_at_cms.hhs.gov.

2
2
3
Introduction
4
Introduction Next Steps

• CMS published interpretive guidelines for Acute
  Hospitals for Infection Prevention and Control
  and ASP March 2023
• CMS will publish the rule in a transmittal
• Will update the CoP manual - eventually
• Hospitals will need to review and implement the
  requirements
• Can do a gap analysis where they go through it
  line by line and document how they meet
  compliance

5
CMS Hospital CoP Changes
6
QAPI Program
7
Psychiatric Hospitals
8
Patient Rights and Non-Discrimination
9
PAs Ordering Restraint and Seclusion
10
Emergency Preparedness
11
HP for Healthy Outpatients
12
LAB Look Back Program
13
Nursing Services
14
Medical Staff Autopsies
15
4 Swing Bed Changes
16
CDC Guide to Infection Prevention for Outpatient
Settings
17
Infection Control and Antibiotic Stewardship
18
CAH Infection Control and ASP,Staffing and More
19
APPENDIX

• Resources and Internet Links

20
Patient Rights and Medical Records
Register Now