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CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 What PPS Hospitals Need to Know

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 What PPS Hospitals Need to Know. Speaker. Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting Board Member Emergency Medicine Patient Safety Foundation www.empsf.org

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CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014 What PPS Hospitals Need to Know

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  1. CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2014What PPS Hospitals Need to Know

  2. Speaker Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting Board Member Emergency Medicine Patient Safety Foundation www.empsf.org 614 791-1468 sdill1@columbus.rr.com 2 2

  3. You Don’t Want One of These

  4. The Conditions of Participation (CoPs) • Many revisions since manual published in 1986 • Manual updated January 31, 2014 • Many changes June 7, 2013 • First regulations are published in the Federal Register thenCMS publishes the Interpretive Guidelines and some have survey procedures 2 • Hospitals should check this website once a month for changes 1 http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR 2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

  5. Subscribe to the Federal Register http://listserv.access.gpo.gov/cgi-bin/wa.exe?SUBED1=FEDREGTOC-L&A=1

  6. CMS Survey and Certification Website www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage Click on Policy & Memos

  7. CMS Issues Many Changes in 2013 • CMS publishes 165 page final regulations changing the CMS CoP • Published in the May 16, 2012 Federal Register and final interpretive guidelines published 3-15-2013 and effective June 7, 2013 • CMS publishes to reduce the regulatory burden on hospitals-more than two dozen changes • Published other changes since then • Includes changes regarding plan of care, restraint and seclusion, drug orders, verbal orders, blood transfusions, IV medications, and standing orders

  8. CMS Updates to Manual

  9. Feb 4, 2013 Proposed Changes • CMS issues 114 pages related to proposed changes to the CMS CoP • Hospital privileges for RD to write diet orders • Board must consult with chief medical officer for each individual hospital rea quality of medical care provided in the hospital • Confirmed each hospital must have separate medical staff • MS can include PharmD, dieticians, PA, NP, etc. • No requirement for board to include MD/DO

  10. Feb 4, 2013 Proposed Changes • Allow practitioners not on MS to order outpatient services • Allow in-house preparation of radiopharmaceuticals on off hours without a physician or a pharmacist being present • 3 changes for hospitals that are transplant centers • ASC change for radiology services incident to the surgery • Swing beds move to Part D so accreditation organizations can survey • CAH P&P committee deleted requirement for non staff member requirement

  11. Feb 4, 2013 Proposed Changes www.ofr.gov/inspection.aspx

  12. How to Keep Up with Changes • First, periodically check to see you have the most current CoP manual1 • Once a month go out and check the survey and certification website 2 • Once a month check the CMS transmittal page 3 • Have one person in your facility who has this responsibility • 1 http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf • 2 http://www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage • 3 http://www.cms.gov/Transmittals

  13. Location of CMS Hospital CoP Manual New website www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

  14. CMS Hospital CoP Manual www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

  15. Transmittals www.cms.gov/Transmittals/

  16. CMS Survey Memos Issued • Survey memo issued March 15, 2013 with changes • Privacy and confidentiality memo on March 2, 2012 • Complaint manual updated April 19, 2013 • Access to hospital deficiency data March 22, 2013 • Use of insulin pens issue May 18, 2012 • Single dose June 15, 2012, Humidity in OR 2013 • Discharge planning rewritten May 17, 2013 • Reporting to internal PI March 15, 2013 • Luer Misconnections March 8, 2013, Equipment Dec12, 2013

  17. Luer Misconnections Memo • CMS issues memo March 8, 2013 • This has been a patient safety issues for many years • Staff can connect two things together that do not belong together because the ends match • For example, a patient had the blood pressure cuff connected to the IV and died of an air embolism • Luer connections easily link many medical components, accessories and delivery devices

  18. Luer Misconnections

  19. PA Patient Safety Authority Article

  20. June 2010 Pa Patient Safety Authority

  21. ISMP Tubing Misconnections www.ismp.org

  22. TJC Sentinel Event Alert #36 www,jointcommission.org http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/ http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/ http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/ http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/ http://www.jointcommission.org/sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/

  23. CMS Hospital Worksheets Third Revision • October 14, 2011 CMS issues a 137 page memo in the survey and certification section • Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey • Addresses discharge planning, infection control, and QAPI • It was pilot tested in hospitals in 11 states and on May 18, 2012 CMS published a second revised edition • Piloted test each of the 3 in every state over summer 2012 • November 9, 2012 CMS issued the third revised worksheet which is now 88 pages

  24. CMS Hospital Worksheets • Will select hospitals in each state and will complete all 3 worksheets at each hospital • This is the third and most likely final pilot and in 2014 will make some revisions and CMS will use whenever a validation survey or certification survey is done at a hospital by CMS • Third pilot is non-punitive and will not require action plans unless immediate jeopardy is found • Hospitals should be familiar with the three worksheets

  25. Third Revised Worksheets www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage

  26. CMS Hospital Worksheets • The regulations are the basis for any deficiencies that may be cited and not the worksheet per se • The worksheets are designed to assist the surveyors and the hospital staff to identify when they are in compliance • Will not affect critical access hospitals (CAHs) but CAH would want to look over the one on PI and especially infection control • Questions or concerns should be addressed to PFP.SCG@cms.hhs.gov

  27. Access to Hospital Complaint Data • CMS issued Survey and Certification memo on March 22, 2013 regarding access to hospital complaint data • Includes acute care and CAH hospitals • Does not include the plan of correction but can request • Questions to bettercare@cms.hhs.com • This is the CMS 2567 deficiency data and lists the tag numbers • Updating quarterly • Available under downloads on the hospital website at www.cms.gov

  28. Access to Hospital Complaint Data • There is a list that includes the hospital’s name and the different tag numbers that were found to be out of compliance • Many on restraints and seclusion, EMTALA, infection control, patient rights including consent, advance directives and grievances • Two websites by private entities also publish the CMS nursing home survey data • The ProPublica website for LTC • The Association for Health Care Journalist (AHCJ) websites for hospitals

  29. Access to Hospital Complaint Data

  30. Can Count the Deficiencies by Tag Number

  31. Lists by State and Names Hospitals

  32. Complaint Manual Update • CMS issues memo on April 19, 2013 • CMS updates the Complaint Manual • Hospital found to be in immediate jeopardy could have a full validation survey if the RO requests it • Regional office has discretion • Hospital can be placed on 23 or 90 days termination track depending on if IJ removed • GAO emphasized need to share complaint information and SA survey finding with the applicable accreditation agency and CMS agrees • TJC, DNV,AOA, or CIHQ

  33. Complaint Manual Update

  34. TJC Revised Requirements • TJC has published many changes over the past two years • Many of the changes reflected in their standards is to be in compliance with the CMS CoP • Standards are for hospitals that use them to get deemed status to allow payment for M/M patients • This means hospitals do not have to have a survey by CMS every 3 years • Can still get a complaint or validation survey • So now TJC standards crosswalk closer to the CMS CoPs • Not called JCAHO any more

  35. Mandatory Compliance • Hospitals that participate in Medicare or Medicaid must meet the COPs for all patients in the facilities and not just those patients who are Medicare or Medicaid • Hospitals accredited by TJC, AOA, CIHQ, or DNV Healthcare have what is called deemed status • These are the only 4 that CMS has given deemed status to for hospitals and possible 5th one called AAHHS • This means you can get reimbursed without going through a state agency survey • States can still institute a survey and be more restrictive

  36. CMS Hospital CoPs • All Interpretative guidelines are in the state operations manual and are found at this website1 • Appendix A, Tag A-0001 to A-1164 and456 pages long • You can look up any tag number under this manual • Manuals • Manuals are now being updated more frequently • Still need to check survey and certification website once a month and transmittals to keep up on new changes 2 1http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf 2 http://www.cms.gov/Transmittals/01_overview.asp

  37. Location of CMS Hospital CoP Manual All the manuals are at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

  38. Conditions of Participation (CoPs) • Important interpretive guidelines for hospitals and to keep handy • A- Hospitals and C-Critical Access Hospitals • C-Labs • V-EMTALA (Rewritten May 29, 2009 and amended July 2010) • Q-Determining Immediate Jeopardy • I-Life Safety Code Violations • All CMS forms are on their website

  39. Contact for Questions • Resource is your state department of health or regional CMS office • The American Hospital Association or state hospital association may be of assistance • Note that when changes are published in the Federal Register or CMS Survey Memo there is always the name and phone number of a contact person at CMS to contact for questions

  40. Compliance Recommendation • Assign each section of the hospital CoPs to the manager of that department • Do a side by side gap analysis like the TJC PPR for each section • Have standard on left side and go line by line and document compliance on the right side • Keep a hard copy of CoP and analysis • Designate someone in charge if a validation, complaint, or unannounced survey occurs • Commonly referred to as the CoP king or queen

  41. CMS Required Education • These will be discussed throughout presentation: • Restraint and seclusion (annual) • Abuse, neglect and harassment (annual) • Infection control, Advance directive • Medication errors, drug incompatibility and ADR • Organ donation, standing orders & protocols • IVs and blood and blood products P&P, medication timing • ED common emergencies, IVs and blood and blood products for ED

  42. What’s Really Important • Life Safety Code Compliance • Infection Control and CMS received $50 million grant to enforce and now HHS gets 1 billion • Patient Rights especially R&S and grievances • EMTALA • Performance Improvement (CMS calls it QAPI) • Medication Management • Dietary and cleanliness of dietary • Infection control issues in dietary is big!

  43. What’s Really Important • Verbal orders • History and physicals • Need order for respiratory and rehab (such as physical therapy) • Need order for diet, medications, and radiology • Anesthesia (updated four times) • Standing orders and protocols • Medications within 30 minute time frame • Note the CMS Deficiency Memo

  44. Survey Protocol • First 37 pages list the survey protocol, including sections on: • Off-survey preparation • Entrance activities • Information gathering/investigation • Exit conference • Post survey activities

  45. Survey Protocol • Survey done through observation, interviews, and document review • Usually surveys are done Monday - Friday but can come on weekends or evenings • Federal law allows CMS or department of health surveyors access to your facility • CAH rehab or psych (behavioral health) is surveyed under this section even though CAH has a separate manual

  46. Survey Team • Mid-sized hospital with a full survey • Two to four surveyors for three or more days and at least one RN with hospital survey experience • Team based on complexity of services offered • SA (state agency) decides or RO (regional office) for federal teams • Have an organized plan for an unannounced survey with designated persons to accompany surveyors • Include education of security or those who attend to the front desk where surveyors could enter in the morning

  47. Deficiency • Condition level- (NOT GOOD) due to noncompliance with requirement in a single standard or several standards within the condition or single tag but represents a severe or critical health breach, (need to have conversation) • Standard level- noncompliance as above but not of such a character to limit facility’s capacity to furnish adequate care - no jeopardy or adverse effect to health or safety of patient • Try and work with the surveyor to resolve the issue before CMS leaves the building

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