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Course "The CMS Hospital Conditions of Participation (CoPs) Made Easy 2018" has been pre-approved by RAPS as eligible for up to 10 credits towards a participant's RAC recertification upon full completion.

If a CMS surveyor showed up in your hospital tomorrow, would you be prepared? This seminar will cover the entire CMS Hospital CoP manual. It is a great way to educate everyone in your hospital on all the sections in the CMS hospital manual especially ones that applies to their department. Hospitals have seen a significant increase in survey activity by CMS.

This program will also include the proposed changes in 2018 on discharge planning and the IMPACT Act. The hospital will need to get the discharge summary in the hands of the primary care physician within 48 hours. There are five new quality measures, five new things to add to the assessment form, medication reconciliation, providing written information on side effects of medication, five things that will have to be in the discharge instructions and more.

The 2018 proposed changes in the Hospital Improvement Rule will be discussed. This makes many changes including a requirement for an antibiotic stewardship program and changes to nursing, medical records, QAPI, and more.

Learning Objectives:

At the conclusion of the program, participants will be able to:

  • Recall that all hospitals that accept Medicare and Medicaid have to be in compliance with all of the hospital conditions of participation and for all patients
  • Discuss that CMS has issued the final worksheets on QAPI, infection control, and discharge planning
Seminar Fee Includes:
AM-PM Tea/Coffee
Seminar Material
USB with seminar presentation
Hard copy of presentation
Attendance Certificate
$100 Gift Cert for next seminar
  • Discuss that CMS has completely rewritten the discharge planning standards
  • Describe that CMS has patient rights standards, which are the most problematic standards in the hospital CoP manual
  • Recall that there are many educational requirements for restraint and seclusion
  • Discuss that medical records section has the requirements for verbal orders which have been problematic for hospitals
  • Discuss the importance of making sure all protocols are approved by the Medical Executive Committee (MEC) and that an order is entered in the chart
  • Discuss that CMS has sections in the hospital CoP manual of informed consent, advance directives and contact management

Who Will Benefit:

  • CEO, COO, Chief Nursing Officer, Chief Medical Officer, Management Team, Department Directors
  • Case Managers
  • Quality Managers
  • Consumer Advocate
  • Nurse Educators, Nurse Managers, Nurses
  • Risk Managers
  • Hospital Legal Counsel, Compliance Officers, Joint Commission Liaison
  • Director of Health Information
  • Joint Commission, Coordinator
  • Patient Safety Officer, Patient Safety Committee, Outpatient
  • Director, Director of Rehab, Dieticians, Respiratory Therapy Director, Director of Radiology, Infection Preventionist
  • Infection Control, Medication, Anesthesia and Surgery staff
  • PACU Director
  • Committee, Policy and Procedures
  • Pharmacist, Pharmacy Director
  • Social Workers
  • Discharge Planners
  • PI Coordinator

Topic Background:

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. This 525 page manual has interpretive guidelines that must be followed for all patients treated in the hospital or hospital owned departments. Facilities accredited by the Joint Commission (TJC), HFAP, CIHQ, and DNV Healthcare must follow these regulations.

The November 20, 2015 manual implemented ten tag number changes in pharmacy and tag 405 in nursing. The July 10, 2015 manual rewrote all of the radiology and nuclear medicine sections. The October 9, 2015 included the definition of spouse for individuals of same sex marriages.

The interpretive guidelines serve as the basis for determining hospital compliance and there have been many changes in the recent years. There have been significant changes and many important survey memos issued also. CMS issued the final surveyor worksheets for assessing compliance with the QAPI, infection control and discharge planning standards. The proposed changes to the infection control worksheet will be discussed. The worksheets are used by State and Federal surveyors on all survey activities in hospitals when assessing compliance.

Changes in the recent past were made to the medical staff, board, radiology, nuclear medicine, UR, nursing, pharmacy, dietary and outpatient regulations. There were changes to discharge planning, safe opioid use, IV medication, blood and blood products, safe opioid use, privacy and confidentiality, visitation, informed consent, advance directives, rehab and respiratory orders, radiology, QAPI, preventive maintenance, timing of medication, telemedicine, standing orders, informed consent, plan of care, humidity level, Complaint manual and reporting the accreditation organizations, organ procurement contracts, and adverse event reporting to the QAPI program. There were also a record breaking number of survey and certification memos issued over the past few years.

There also are sections on medical record services, dietary, utilization review, emergency department, surgical services, anesthesia, PACU, medical staff, nursing services, outpatient department, rehabilitation, radiology, respiratory, physical environment, infection control, organ and tissue, patient rights and discharge planning. Hospitals should perform a gap analysis to ensure they are compliant with all these interpretive guidelines and assign one person to be responsible for ensuring compliance.

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Day 01(8:30 AM - 4:00 PM)
  • 08:30 AM – 09:00 AM Registration
  • 09.00 AM: Session Start
  • Overview of the CMS Survey Process and Introduction
    • Introduction
    • Location of the manual
    • Proposed changes in 2018
    • Revisions in 2015 and 2016
    • Hospital revised worksheets; infection control, PI, and discharge planning
    • Changes in recent past
      • Medication and safe opioid use, medical staff, board, radiopharmaceuticals, dieticians ordering diet, ordering outpatient services, separate MS or unified integrated MS, etc.
    • Changes and memos
      • Privacy, Legionella, confidentiality, rehab, timing medications, medication errors, humidity, reporting to internal PI, Ebola, worksheets, luer misconnection, safe opioid use, safe injection practices, infection control breeches, organ procurement contracts, deficiency memos, etc.
    • CMS required education
    • What’s really important
    • Survey protocols
    • Survey team
    • Compliance with law
    • Order sets, protocols, standing orders
  • Board and CEO
    • Board requirements
    • 38 pages of changes Sept 2014
    • MS by-laws
    • Appointment to the MS
    • Credentialing and privileges
    • TJC tracer on C&P
    • Medical staff and the board
    • Single medical staff or unified integrated MS
    • Privileging others such as PharmD, podiatrist, RD, etc.
    • Telemedicine
    • CEO requirements
    • Care of patients
    • Plan and budget
    • Contracted services
    • Emergency services
  • Medical Records (Health Information Management)
    • Proposed changes in 2018
    • Final drug and alcohol federal law (substance use disorder records)
    • Organization and staffing
    • Confidentiality of records
    • Content of records
    • Legibility requirements
    • Authentication
    • Informed consent mandatory and optional elements
    • H&P
    • Verbal orders
    • Signature stamps and guidelines
    • Discharge summary
    • Recall that CMS has restraint standards that hospitals must follow
    • Describe that the patient has a right to file a grievance and the hospital must have a grievance policy and procedure in place
    • Recall that interpreters should be provided for patients with limited English proficiency and this should be documented in the medical record
  • Patient Rights
    • Proposed changes in 2018
    • Right to privacy and safety
    • Confidentiality
    • Designation of a representative
    • Right to an IM Notice for Medicare patients
    • Understanding what is a patient advocate/support person
    • Interpreters
    • Low health literacy
    • Advance directives
    • Informed consent
    • Abuse and neglect
    • Criminal background checks
    • Grievances and complaints (TJC)
    • Visitation requirement
    • Patient representative
    • IM Notice for Medicare patients
    • Family member and doctor notification
    • Plan of care
    • Informed consent
    • Advance directives
    • Privacy and confidential
    • Care in a safe setting
    • Privacy and confidentiality memo
    • Patient medical records
    • Access to medical records
    • Restraint and seclusion-high number of deficiencies for hospitals
      • Restraint changes, soft limb restraints and death, internal log verse external log and reporting to CMS, definition, restraint worksheet, right to free from unnecessary R&S, hospital leadership role, definition, medication used as a restraint, R&S do not include, weapons, assessment, less restrictive, alternatives, LIP can order, documentation, education requirements, prn orders, plan of care, end at earliest time, PI, one hour rule, renewing restraint orders, and R&S policy.
    • Visitation
    • Describe that medications must be given timely and within one of three blocks of time
    • Recall that all protocols should be approved by the Medical Staff and an order entered into the medical record and signed off
    • Recall that there are many pharmacy policies required by CMS
    • Recall that a nursing care plan must be in writing, started soon after admission and maintained in the medical record
    • Recall that the hospital must have a safe opioid policy approved by the MEC and staff must be educated on the policy
  • Nursing Services
    • Proposed 2018 changes
    • Director of nursing (CNO)
    • Medication administration and safe opioid use
    • Safe injection practices and compounding
    • Staffing
    • Policies and procedures
    • Nursing care plan
    • Staff competency
    • Preparation and administration of drugs
    • Licensure verification
    • Nursing linked to safety
    • Self-administration of medication
    • IV and blood transfusions
    • Reporting medication errors and ADEs
    • Agency nurses
    • 30 minutes medication rule changes
    • Timing of medication 3
    • Orders, protocols, standing orders, order sets
    • Verbal orders
    • IV medication and blood transfusions
    • Incident reports
  • Pharmaceutical Services
    • Proposed antibiotic stewardship program in 2018
    • Major revision in 2016; BUD, compounding and more
    • November 20, 2015 manual red line pharmacy changes
      • 10 tag numbers revised and new one (490)
    • Administration of medication within 1 hour from preparation of CSP
    • Compounding and amended nursing tag 405
      • Use of compounding pharmacies
      • Obtaining from compounding pharmacy v. manufacturer or registered outsourcing facility
      • BUD, packaging, and labeling of medications
    • Must follow professional standards of care such as USP
    • Best practices recommendations such as ISMP and ASHP
    • Preparing CSPs outside the pharmacy
    • Storage of drugs
    • Radiopharmaceuticals on off hours
    • Pharmacy administration and must meet needs of patients
    • P&P to minimize drug error
    • Standardization of prescribing and communication practices
    • Floor stock
    • Patient safety
    • Drugs and biological
    • First dose review
    • High-risk medication
    • Definitions of medication errors, ADE and DI
    • Notification of physician
    • Policies required and training on policies
    • Pharmacy requirements
    • Storage and security of medications
    • Self-administration of medication
    • Outdated or mislabeled medications or unusable drugs
    • Drug interactions and side effects
    • Night pharmacy cabinet standards
    • PI requirements for adverse drug events
    • Recall that CMS has patient safety requirements in the QAPI section that are problematic standards
    • Describe that CMS requires many radiology policies include one on radiology safety and to make sure all staff are qualified
    • Discuss that a hospital can credential the dietician to order a patient’s diet if allowed by the state
  • Medical Staff, Board, and CEO
    • Shared medical staff, board consults at least twice a year, etc.
    • MS by-laws
    • Changes to MS
    • Appraisal of MS
    • Accountability of MS for quality of care
    • Credentialing and privileging
    • CEO requirements
    • History and physicals
    • Autopsy requirements
  • Quality Assessment and Performance Improvement
    • PI program requirements
    • Proposed 2018 changes
    • QAPI worksheet
    • Revised tag numbers
    • Tracking of medical errors and adverse events
    • Identifying opportunities for improvement
    • Patient safety
  • Radiological Services
    • Rewritten July 10, 2015
    • Radiation exposure
    • Adverse reaction to agents
    • Secure area for films
    • Safety precautions
    • Shielding of patients
    • Order required
    • Supervision of staff
    • Signing of radiology reports
    • changes radiopharmaceuticals on off hours
  • Laboratory Services and Look Back Program
    • Lab services
    • Tissues specimens
    • Blood bank
    • Look back program
    • Fully funded plan
  • Food and Dietary Services
    • Diets and menus
    • Changes RD or nutrition specialist to write diet orders
    • Patient nutritional needs
    • Diet manual and therapeutic menus
    • Qualified director required
    • Dietary policies required
    • Nutritional assessment
    • Infection control is important!
    • Order required
    • Therapeutic diets and nutritional needs
  • Utilization Review
    • Composition of UR committee
    • Admission or continuous stays
    • Medicare patient discharge appeal rights
    • UR plan
    • Scope of reviews
    • Notice Law and MOON form
  • Physical Environment
    • Buildings and equipment
    • 2017 changes emergency preparedness moved to new appendix Z
    • Compliance with PI
    • Life safety code
    • Trash
    • Emergency preparedness
    • Emergency power and lighting
    • Emergency gas and water
    • Ventilation, light, temperature
Day 02(8:30 AM - 1:00 PM)
  • Objectives:
    • Discuss that CMS requires many policies in the area of infection control
    • Recall that patients who are referred to home health and LTC must be given a list in writing of those available and this must be documented in the medical record
    • Describe that all staff must be trained in the hospital’s policy on organ donation
    • Understand that CMS has specific things that are required be documented in the medical record regarding the post-anesthesia assessment
    • Recall that CMS has finalized the discharge planning worksheet
  • Infection Control and 2018 Proposed Changes
    • Infection preventionist
    • Final infection control worksheet
    • IC revised worksheet and importance
    • IP responsibilities
    • Policies and procedures required
    • Mitigation of risks
    • Safe injection practices
    • Immediate use
    • Medical equipment and supplies
    • Log of incidents
    • Mandatory training
  • Discharge Planning
    • Proposed changes in 2017/2018 and IMPACT law
    • Final discharge planning worksheet
    • Identification of patient needs,
    • Discharge planning and evaluation
    • Patient provided written copy of Home health and LTC
    • Discharge planning responsibility
    • Identification of patients
    • Transfers
    • Referrals
    • Self care
    • Timely discharge evaluation
    • Discharge plan and self care evaluation
    • Remember the CMS discharge planning worksheet
  • Organ, Tissue and Eye Procurement
    • Policy requirements
    • Board required
    • Organ donation training
    • Family notification
    • OPO Notification one call rule
    • CMS OPO memo
  • Surgical & Anesthesia Services
    • Follow standards of care
    • Policies required
    • Supervision requirement
    • Preventing OR fires
    • H&P
    • Consent
    • OR register
    • Operative report
    • Required equipment
    • PACU
    • Anesthesia policies required
    • Anesthesia and analgesia standards
    • Pre and post-anesthesia requirements
    • Anesthesia staffing
    • Documentation required
    • Intra-operative anesthesia record
  • Outpatient Services and proposed 2018 changes
    • No longer accountable to single individual
    • Policies and procedures
    • Meeting needs of patients
    • Outpatient orders
  • Emergency Services
    • Following standards of practice
    • Integrated into hospital PI
    • Qualified medical director
    • Policies required
    • Length of time to transport between departments
    • EMTALA
  • Rehabilitation and Respiratory Services
    • Following standards of practice
    • Integrated into hospital PI
    • Qualified medical director
    • Policies required
    • Length of time to transport between departments
    • EMTALA
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Sue Dill Calloway

Sue Dill Calloway, RN, AD, BA, BSN, MSN, JD, CPHRM
President at Patient Safety and Healthcare Education & Consulting

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications.

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