Nursing Quality Measures for 2024: CMS Hospital Requirements

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HOSPITAL CONDITIONS OF PARTICIPATION
(COPS) 2024 Nursing SectionsAcute and Critical
Access Hospitals

• Presented By
• Laura A. Dixon, BS, JD, RN, CPHRM
• Healthcare Risk Education Consulting, LLC

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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.

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2020 Changes to Nursing Sections

• Hospital Improvement Rule

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Nursing Section Changes

• Clarified
• Need nursing supervisor
• Sufficient staff
• Immediate availability of RN at the bedside to
  respond when needed
• Must have current nursing care plan
• Must have evidence of reassessment and include
  patient goals and treatment preferences
• All nurses, not just agency nurses, must follow
  PPs
• CNO must evaluate all clinical activities of
  nurses
• Including agency nurses and other staff
• Need an order for drugs
• Except flu and pneumovax when you have a protocol
• Verbal orders are to be used infrequently
• Must have PP prohibiting discrimination
• Cannot discriminate against race, color, national
  origin, disability, etc.
• Not in CoP but OCR 1557 requirement
• Must inform patient
• In writing
• In a language they can understand
• Of right to be free from discrimination

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CMS Memos and Nursing Section
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6 Areas of Concern

• Areas of concern on missing or inaccurate
  information
• 1. Medications
• 2. DMEs
• 3. Skin conditions (tears)
• 4. Communications with PACs/caregivers on needs
  at home
• 5. Patients with serious mental illness, SUDs,
  complex behavior needs
• 6. Preferences and goals for care

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Non-Discrimination and Interpreters

• Section 1557 and Nursing

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Nursing Conditions of Participation

• Tag Nos. 385 413

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Critical Access Hospitals Provisions of Services
Nursing

• Tag Nos. C 1046 - 1050

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Nursing Service and Leadership

• Nursing service must be well-organized
• Need designated person responsible for nursing
  services
• Responsible for development of nursing PPs
• Expected to be an RN
• Title CNO, DNO, Nurse manager

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Content of Medication Order

• Patient name
• Age and weight dose calculation
• Date and time of order
• Drug name
• Exact strength or concentration (when applicable)

• Dose, frequency and route
• Dose calculation requirements (if applicable)
• Quantity and/or duration (when applicable)
• Name of prescriber

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Nursing Care Plan

• Plan develops appropriate nursing interventions
  based on identified needs
• Must be part of the permanent medical record
• Nursing can do as part of the interdisciplinary
  POC
• BUT - must still do a nursing plan of care
• Surveyor will check to make sure POC started soon
  after admission
• Will also make sure it is revised as necessary

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Manual Sections That Impact Nursing

• Outside Nursing Standards

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The End Questions???

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education, and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net

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