Catalog Number : ngd1130
Title : CMS Nursing Standards
Speaker : Sue Dill

Webplay Recording Date : 5-18-2016
Webplay Price : $ 150 for two weeks viewing

Webinar Overview:

This webinar will cover the nursing services section in the hospital CoP manual. Plus it will also reference other important sections that all nurses should be aware that are found outside the nursing services section (i.e. medication standards, verbal orders, history and physicals, etc.).

***Please note that CMS has a separate CoP for Critical Access Hospitals (CAHs). Although there are many similar standards in the nursing services section it is important to note that CMS has a separate manual for CAHs and differences do exist.

Webinar Objectives:

• recall that CMS has a section on nursing services that every hospital must follow even if accredited
• describe that all medications must be administered within three different time frames
• discuss that nursing care plans are a frequently cited area by CMS and recall a recent change
• recall that all verbal orders must be signed off and need to include both a date and time

Webinar Outline:

• Introduction into the CMS hospital CoPs
• Where to locate a copy
• CMS deficiency reports and problematic standards
• How to get apprised of changes
• Changes to medication management, IV, blood, and opioid safe use
• Proposed changes under the Hospital Improvement Act
• ISMP IV push guidelines
• Safe injection practices
• Changes related to safe injection practices, compounding, medication preparation, immediate use, and labeling
• Revised CMS Hospital work sheets and importance
• Recent CMS memos of interest
  • Rewrote all the discharge planning standards
  • Hospital deficiencies
  • Reporting to the PI system
  • Insulin pens and safe injection practices
  • New interpretive guidelines
  • Luer misconnections
  • Organ Procurement Organization Contracts
  • Discharge planning standards
  • CMS complaint manual
  • Humidity in the OR
• Federal regulation changes
• Final interpretive guidelines and changes
• Most current CMS Manual
• Many recent changes to 9 tag numbers
• Starts at Tag 385 and goes to tag 413
• Nursing Services and 24 hours services
• Insulin pen and safe injection practices
• Third revised worksheet
• RN on duty
• Integrated with hospital wide PI program
• Organizational chart and nursing
• Chief Nursing Officer (CNO) responsibilities
• CNO requirements
• CNO approval of nursing policies
• Staffing and delivery of care
• 24 hour nursing services and supervision
• Valid license for nurses and verification
• RN to evaluate to care of all patients
• Nursing care plans
• Changes to the plan of care
• Agency nurse requirements
• Orientation of agency nurses
• Medication administration
• Order required for all medications
• Standards of care and practice to prevent HAI
• BUD, compounding sterile preparations (CSP)
  • Immediate use CSP
  • Administration one hour rule
• Safe injection practices
• Standing orders and protocols
• Three medications timing changes
• Protocols, standing orders, order sets
  • Tag 405 standards moved to 457
• Requirements for complete drug order
• Verbal orders
• Blood transfusions and IV medications changes
• Self-administered medications

Other important sections nurses should be aware of:

• Restraint and seclusion changes
• Grievances
• Medications policies
• Visitation
• History and physicals

Target Audience:

Chief Nursing Officer, all nurses, Nurse Managers, Nurse Supervisors, Nurse Educator, HIM staff, Compliance Officer, Chief of Medical Staff, Medical Staff Coordinator, Risk Manager, Patient Safety Officer, senior leadership, documentation specialist, hospital legal counsel, PI Director, Joint Commission Coordinator, Regulatory Officers, Chief Operating Officer, Chief Medical Officer, physicians, Education Department Staff, board members, Director of Health Information Management, audit staff, and others responsible for compliance with hospital regulations including documentation compliance

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.