Ensure your hospital's nursing services comply with CMS Conditions of Participation (CoPs) to maintain Medicare and Medicaid reimbursement eligibility. Join our webinar as we delve into crucial aspects of the CoP manual, including plans of care, staffing requirements, policy changes for outpatient departments, documentation standards, supervision protocols, nursing leadership expectations, and more. Discover the latest updates and anticipated interpretive guidelines for the nursing chapter of the CoPs, addressing areas frequently cited in compliance assessments. With nursing services cited over 8,900 times in recent reports, understanding these regulations is paramount. We'll also explore past changes in nursing regulations, such as medication timing, standing orders, blood transfusions, IV medication administration, self-medication protocols, and drug order procedures. Stay informed about evolving non-discrimination regulations under Section 1557 and other manual sections affecting nursing practices. Don't miss this opportunity to ensure your hospital's nursing services meet regulatory standards and optimize patient care. Register now to stay ahead of compliance requirements and enhance your facility's operations. Register, https://conferencepanel.com/conference/nursing-standards-cms-condition-of-participation-for-hospitals

1. HOSPITAL CONDITIONS OF PARTICIPATION
(COPS)
2024 Nursing Sections
Acute and Critical Access Hospitals
Presented By:
Laura A. Dixon, BS, JD, RN, CPHRM
Healthcare Risk Education & Consulting, LLC

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@cms.hhs.gov.
Acute hospitals: qsog_hospital@cms.hhs.gov.
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2

3. 2020 Changes to Nursing
Sections
Hospital Improvement Rule

4. 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 P&Ps
• 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 P&P prohibiting discrimination
• Cannot discriminate against race, color, national origin, disability, etc.
• Not in CoP butOCR 1557 requirement
• Must inform patient
• In writing
• In a language they can understand
• Of right to be free from discrimination
• Must inform the patient

5. CMS Memos and Nursing
Section

6. 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

7. Non-Discrimination and
Interpreters
Section 1557 and Nursing

8. Nursing Conditions of
Participation
Tag Nos. 385 – 413

9. Critical Access Hospitals
Provisions of Services
Nursing
Tag Nos. C 1046 - 1050

10. Nursing Service and Leadership
• Nursing service must be well-organized
• Need designated person responsible for nursing
services
• Responsible for development of nursing P&Ps
• Expected to be an RN
• Title: CNO, DNO, Nurse manager

11. 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

12. 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

13. Manual SectionsThat
Impact Nursing
Outside Nursing Standards

14. The End Questions???
•Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk
Education, and Consulting, LLC
• 303-955-8104
• ldesq@comcast.net
Register Now