CMS Hospital Improvement FINAL RuleS Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI, and more

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CMS has 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 include changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. 

Most have an effective date of November 29, 2019 with two exceptions. The normal implementation date is 60 days but Critical Access Hospitals will have 6 months to implement an antibiotic stewardship program and 18 months to implement a QAPI program since their QAPI requirements were completely written.

It will also require all hospitals to have an antibiotic stewardship program and what the program should include. Also a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.

Detailed Outline


• Interpretive guidelines and survey procedure to be issued

• How to get a copy of the CoP manual, survey memos, etc.

• Why revise the CoPs

Psychiatric Hospitals

• Non-physicians writing in progress notes

• How often progress notes must be written

Emergency Preparedness

• Staff training every two years

• Exercises twice a year

• EP policies and procedures

• Emergency plan

H&P Changes

• When is a H&P required

• Assessments instead in healthy outpatients

• Medical staff policy requirements

• Considerations

Patient Rights and Medical Records

• Restraint changes

• Change from LIP to licensed practitioner (LP)

• Physician Assistants (PAs) to order and evaluate

• Non-discrimination under OCR 1557

o Written policy prohibiting

o Inform each patient on prohibition against discrimination

o Inform on how to file a complaint

o Currently already a law and CMS decides NOT to include in the CoPs

• Medical Records section was not implemented

o Content of medical records

o Document complications and hospital acquired conditions

o Diagnosis in outpatient record in 7 days

o Discharge instructions and transfer summaries


• Quality indicator data including patient care data

• Medicare Quality Reporting Data

• Hospital readmission data

• Hospital acquired conditions (HACs) and 5 changes

Nursing Services and Outpatient Departments

• Staffing-adequate number

• Supervisory staff

• Need to respond immediately when needed

• Nursing care plans

• Policies and procedures

• CNO must evaluate nursing staff including agency staff

• All outpatient departments must identify if RN must be present

• Outpatient policy required

• P&P must be reviewed by MEC

• Orders for drugs and biologicals

• Verbal orders

Look Back Program and the Lab

• Notification of tainted blood

• Patient notification process

• Time frame for notification


• Deleted requirement to get in unusual cases

• Coroner cases

Four swing bed changes

• Dental 

• Activity program and assessment and plan of care

• Social worker

• Residents performing services

Infection Control and Antibiotic Stewardship

• Hospital wide surveillance

• CDC outpatient assessment tools

• Following national recognized standards and best practices

• Infection control hospital wide QAPI program

• Infection control program and policies requirements

• Qualified infection preventionist

• Requirements for the antibiotic stewardship program

o Qualified leader who must be appointed by the board

o Active program and evidenced based use of antibiotics

o Document improvements and reduction of CDI

o Board responsibilities

o Responsibilities of leader of antibiotic stewardship program

• Antibiotic stewardship policies

• Tracking all infections

• QAPI leadership

• Competency based staff training

Who Should Attend?

Pharmacist, chief nursing officer, health information management, infection preventionist, antimicrobial stewardship team members, nurses, nurse educators, chief medical officer, QAPI director and staff, patient safety officers, regulatory and compliance officers, physician assistants (PAs), patient advocate, risk management, nurse educators, hospital legal counsel, MEC chair, board members, and anyone involved in implementing the hospitals CoPs. 


• 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 a RN

• Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths

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