CMS Hospital Improvement Act Proposed Changes: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI


Instructor: Sue Dill Calloway
Product ID: 705197

  • Duration: 120 Min
This program is going to cover the proposed changes that CMS wants to make for all hospitals including critical access hospitals. These changes will affect many different departments of the hospital including nursing, QAPI, medical records, lab, restraint standards, discrimination, patient rights, and more.
Last Recorded Date: Dec-2018


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Why Should You Attend:

Currently, only 68% of hospitals have an antibiotic stewardship program. This is one of the many things that CMS is proposing to change. Also the Office of Civil Rights have found that many hospitals are not using interpreters at all times indicated. CMS is proposing to implement similar standards to make it clear when interpreters must be used for patients with limited English proficiency. OCR has found that 1 in 10 HIPAA complaints surround the patient access to medical records. They produced two important reference materials that many hospitals were not familiar with. CMS noted this in their proposed rules and have made provisions to improve patient access to medical records. In fact, there are many examples of where CMS feels hospitals and providers are not doing things which is why they have proposed so many changes that impact nursing, nursing plans of care, medical records, outpatient services and more. CMS also found that there is inadequate documentation of care provided to outpatients.

CMS has proposed some significant changes to the hospital conditions of participation (CoPs) that every hospital should know including critical access hospitals. This include changes to nursing, medical records, infection control, QAPI, patient rights, and restraint and seclusion. It will also require all hospitals to have an antibiotic stewardship program and what the program should include. It will include a prohibition on discrimination which must be given to patients in writing.

This session by expert speaker, Sue Dill Calloway, RN, MSN, JD, discusses the proposed changes to the CMS Hospital Improvement Act, including nursing, QAPI, medical records, lab, restraint standards, discrimination, patient rights, and more.

Detailed Agenda:

Patient Rights and Medical Records

  • Restraint five changes
  • Change from LIP to licensed practitioner (LP)
  • Physician Assistants (PAs) to order and evaluate
  • Right to access medical records
    • Oral or written request
  • OCR 2016 2 documents
  • Non-discrimination
    • Written policy prohibiting
    • Inform each patient on prohibition against discrimination
    • Inform on how to file a complaint
  • Medical Records
    • Content of medical records
    • Document complications and hospital acquired conditions
    • Diagnosis in outpatient record in 7 days
    • Final diagnosis
    • Discharge instructions and transfer summaries
      • Will also discuss Nov 3, 2015 FR on proposed discharge planning standards related to discharge instructions and transfer summaries
    • Information to monitor patient conditions


  • 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
  • Annual review of P&P
  • Orders for drugs and biologicals
  • Verbal orders

Infection Control and Antibiotic Stewardship

  • Hospital wide surveillance
  • 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
    • Qualified leader who must be appointed by the board
    • Active program and evidenced based use of antibiotics
    • Document improvements and reduction of CDI
    • Board responsibilities
    • Responsibilities of leader of antibiotic stewardship program
  • Antibiotic stewardship policies
  • Tracking all infections
  • QAPI leadership
  • Competency based staff training

Who Will Benefit:

  • Pharmacist
  • Chief nursing officer
  • Health information management
  • Infection preventionist
  • Antimicrobial stewardship team members
  • Nurses
  • Nurse educators
  • Chief medical officer
  • QAPI staff
  • Patient safety officers
  • Regulatory and compliance officers
  • Physician assistants (pas)
  • Patient advocate
  • Risk management
  • Nurse educators
  • Hospital legal counsel
  • MEC chair
  • Board members
  • Anyone involved in implementing the hospitals cops
  • Anyone who is interested in the CMS 5-star rating system
Instructor Profile:
Sue Dill Calloway

Sue Dill Calloway
chief learning officer, Emergency Medicine Patient Safety Foundation

Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer. She has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

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