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Catalog Number : ncd1289
Title : Revisions to the CMS Hospital Conditions of Participation
Speaker : Sue Dill

Duration : 90 minutes

Webplay Recording Date : 3-28-06
Webplay Price : $ 225 for two weeks viewing

Teleconference/Webinar Presenter: Sue Dill Calloway, RN, Esq., AD, BA, BSN, MSN, JD

Teleconference/Webinar Title: Revisions CMS Hosp CoPs

Teleconference/Webinar Level: Intermediate

Teleconference/Webinar Description: This program will go over the four changes to the hospital conditions of participation (not critical access hospitals) that were changed effective September 19, 2005. The changes provide clarification to issues related to physician supervision of patients admitted by midwives, availability of emergency laboratory services, ordering of therapeutic diets and the grievance process, changes to the definition of what constitutes a grievance, and the requirements of how hospitals how to respond to grievance. It will require hospitals to change their policies and procedures on complaints and grievance to comply with the new requirements. The proposed changes to the informed consent standards that is expected out by March, 2006, will also be discussed.

Teleconference/Webinar Objectives:

  • Explain why the hospital must now amend their policy and procedure on complaints and grievance to comply with the new hospital CoP requirements.
  • Describe that therapeutic diets may not be ordered by a dietician but by the practitioner responsible for the patients care.
  • Recognize that the hospitals governing body is responsible to approve the operation of the grievance process and if delegated to the grievance committee to resolve issues, it must be in writing.

Teleconference/WebinarOutline:

1. Governing body

  • Clarification of patients admitted by nurse midwifes
  • Medicare patients admitted by practitioner must be under care of MD/DO
  • Non-Medicare and Medicaid patients
  • Survey procedure

2. Grievance

  • New definition of grievance
  • What is now meant by staff present
  • Billing issues and relationship to grievance
  • Process for prompt resolution of patient grievances
  • When written response is required to be provided by the patient
  • Written complaints and verbal complaints
  • Notifying patient of right to lodge grievance with state agency
  • Grievance committee required
  • Grievance committee make-up
  • Information from patient satisfaction surveys and grievances
  • Abuse, neglect, and patient harm must be grievances
  • Data collection on grievances
  • Survey procedure
  • Governing body and responsibility for grievance policy
  • Delegation by board is required to be in writing
  • Timely referral to state QIO
  • Complaints on quality of care and coverage decisions
  • NODMAR and HINN
  • Grievance procedure must be explained to patient
  • Inclusion in patient rights document
  • Time frame for reviewing grievance
  • 7 day rule and letter sent to patient
  • Hospitals will all need to rewrite their policy and procedure
  • Written response required to patient and legal action exception

3. Emergency lab availability 24 hours a day

  • Hospital must provide lab services 24/7
  • Onsite lab and provision of emergency services
  • Hospital with multiple locations must also have emergency lab services 24/7
  • Off campus lab department
  • Survey procedure

4. Therapeutic diets must be ordered by practitioner

  • Therapeutic diet requirements
  • Documentation of therapeutic diet
  • Nutritional assessment by dietician
  • Dietician can not order therapeutic diet

5. Informed consent proposed changes

  • Current regulation
  • Changes to require names of residents
  • Changes to witness requirement
  • Informed consent as a process 3 relevant sections

Prerequisites: None

Target Audience: Lab director, dietary director, consumer advocate, risk manager, nursing director, nurses especially nurse managers, nurse midwives, medical staff office, compliance officer, CEO, social services director and staff, quality improvement staff and any other hospital staff responsible for handling complaints and grievances. This program is a must for any person who is responsible for handling complaints and grievances for the hospital.

Nursing Contact Hours: This course has been approved for 2.4 Iowa Nursing Contact Hours.  There is usually a reciprocal agreement between state associations to allow these to count for each state. If you have any questions, please ask your state association.

Refund Policy:

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.