This ten-part online seminar series will cover a majority of the CMS Hospital CoP manual – Appendix A. (Psychiatric and Swing Bed requirements are addressed in a separate program.) It is a fantastic way to educate everyone in your hospital on all the sections of the CMS hospital manual, especially ones that apply to their department.

Continuing Education
The Kentucky Hospital Research and Education Foundation is an approved Kentucky Board of Nursing continuing education provider. This offering number 5-0023-12-25-020 is approved for 1.2 contact hours. Participants must attend the entire session, complete the post-session evaluation, and provide nursing license number in order to receive contact hours and be awarded a certificate. No partial credit will be given. The Kentucky Board of Nursing approval does not constitute endorsement of program content.

Overview of the CMS Survey Process and Introduction

• Introduction
• General information and location of the manual
• Hospital deficiency reports
• Memos of interest to hospitals
  • QAPI Interpretive Guidelines
  • Texting of orders
  • Discharge Planning
• Compliance with laws
  • Non-Discrimination, Interpreters and Section 1557 ACA
• CMS required education
• Survey protocols
• Survey team

Emergency Services

• Need for P&P
• Qualified RN to assess patients
• Basic patient care requirements
• Services must meet patient needs
• Following standards of practice
• Integrated into hospital PI
• Qualified medical director
• Policies required
• Training required
• Urgent care clinics

Outpatient Services 

• Policies and procedures
• Meeting needs of patients
• Outpatient orders
• Documentation of care given in the OP department
• Orders required
• Department director job description and responsibilities
• Recall that CMS has restraint standards that hospitals must follow
• Describe how non-physician practitioners – PA, NPs – can order restraints
• Describe the requirements for reporting patient death while in restraints
• Recall the required education for all personnel who apply or remove restraints

Appendix and Resources