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CMS Hospital Nursing CoP Standards 2014 Webinar By MentorHealth

2/17/2014 10:00 AM - 11:30 AM

There are many changes to the final interpretive guidelines effective June 7, 2013 and August 30, 2013 with a new CoP hospital manual being issued August 30, 2013. In fact, there were two new tag numbers added to the nursing standards section and changes to seven existing sections including tags 405-409 and 410 through 413. Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual.

Facilities accredited by the Joint Commission, American Osteopathic Association, CIHQ, and DNV Healthcare must also follow these regulations. Recently, there has been increased scrutiny and surveillance to make sure that all hospitals are in compliance with the hospital CoPs. Don't be caught off guard and put your hospital's reimbursement at risk. This program will also reference other important sections that all nurses should be aware that are found outside the nursing services section such as medication standards, verbal orders, history and physicals, visitation, restraint and seclusion and grievances, and privacy and confidentiality.

CMS issues the privacy and confidentiality memo, safe injection practices memo and insulin pen memo. This program will include what is in the CMS discharge planning worksheet. It will include tips to prevent unnecessary readmissions. This section contains many problematic standards for hospitals including the nursing care plan standards and that an order is required for all medication especially if standing order or protocol used. Staffing, medications, new three time frame for administering medications and educational requirements will be discussed along with changes standing orders and protocols.

Areas Covered in the Session:

Introduction into the CMS hospital CoPs

Where to locate a copy

How to get apprised of changes

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

Discharge planning standards

CMS complaint manual

OPO contract

Hospital complaint manual and reported to AO memo

Humidity memo

Interpretive guidelines effective June 7, 2013 and August 30, 2013

New Manual issued

Many recent changes to 9 tag numbers

Starts at Tag 385 and goes to tag 413

Nursing Services and 24 hours services

Third revised worksheet

Social Security Administration Act 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

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

Verbal orders changes

Blood transfusions and IV medications changes

Self administered medications

Other important sections nurses should be aware of:

Restraint and seclusion changes


Medications policies


Who Will Benefit:

Chief nursing officer (CNO)

Nurse Managers

HIM Staff

Compliance Officer

Chief of Medical Staff

Medical Staff Coordinator

Risk Manager

Patient Safety Officer

Regulatory Officers

Legal Counsel

Chief Risk Officer

Audit Staff

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 the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation. 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 and risk management issues and writes numerous publications.


Phone No: 800-385-1607

FaX: 302-288-6884

Event Link:

Learn More: CMS Hospital Nursing CoP Standards 2014 Webinar By MentorHealth

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