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New CMS Hospital CoP Manual

CMS has published its new hospital condition of participation (CoP) manual. The manual is dated April 1, 2015, and was published on April 8, 2015. This update was expected and included the information in the CMS survey and certification memo dated Jan. 30, 2015. The CMS hospital manuals are updated more frequently to reflect changes in the regulation or interpretive guidelines. In fact, the CMS hospital manual, Appendix A, was revised five times last year. This is better for hospitals. In the past, the manuals were not updated as frequently and hospitals were frequently not aware that there had been many changes made in the survey memos.

When CMS issues a survey memo, it reserves the right to tinker with the language. When the language is in the final format, CMS will issue a transmittal and then update the CMS manual. Transmittals are also issued to communicate new or changed policies or procedures that will be incorporated in the CMS Online Manual System. CMS issued transmittal R137SOMA, dated April 1, 2015, entitled “Revisions to State Operations Manual (SOM) Appendices A, G, L and T related to Hospitals, Rural Health Clinics, Ambulatory Surgical Centers and Swing Beds.” The transmittal is 56 pages. The transmittal was done to implement the regulations effective July 11, 2014, along with the survey memo issued Jan. 30, 2015. The transmittal and new CMS manual amends, deletes or revises tag numbers in dietary (628, 629, and 630), utilization review (652, 653, and 658), outpatient orders (1076, 1080, and 1081), rehab services (1132) and respiratory therapy (1163).

The April 1, 2015, hospital CoP manual can be downloaded or reviewed here.  

The CMS transmittals can be downloaded from here.

Hospitals should go out and check at least monthly the CMS survey memos, which are here.



CMS Rolls Out Five Star Quality Rating System for HospitalsHPR for Hospital Consult

CMS awarded its first star rating system to hospitals based on patients’ appraisals. This is the first time CMS has introduced star ratings for hospitals which is on hospital compare. Hospital Compare is a website that CMS created so that patients can review the results of certain quality measures of hospitals such as information related to heart attacks, pneumonia or heart failure. CMS created the five-star quality rating system to help patients and families identify the area they may want to ask questions about and to compare hospitals related to the quality of care they deliver. The Affordable Care Act called for more transparency and easier to understand public reporting. It will be updated quarterly.

Data came from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) measures. HCAHPS is a standardized survey tool that collects data based on the patient’s perspective on 11 measures. These have been included in the Hospital compare site. HCAHPS has been used since 2006 to measure quality of care from the patient’s perspective. It looks at topics like how well nurses and physicians communicate with patients, pain management, discharge information, how responsive hospital staff was to meeting the patient’s needs, how well patients were prepared for this discharged hospital setting and how clean and quiet the hospital environment was.

There were only 251 hospitals out of 3,553 hospitals in the US that received the highest score on the new five-star rating system, which is about 7%. Some of the leading hospitals in the country received middle scores. Some hospital officials were concerned that the five-star scale relied too much of the patient’s perspective of quality and that it doesn’t reflect actual quality of care. CMS has been using star ratings for nursing homes and dialysis facilities. This will mostly likely result in encouraging hospitals and practitioners to strive to improve patient experience and quality of care. There were 1,205 hospitals (34%) that received four stars, 1,414 hospitals (40%) that received three stars, 585 hospitals (16%) that received two stars, and 101 (3%) that received one star. There were 1,102 that were not rated because of lack of enough data during the survey period.

More information is here on the CMS site and on this CMS fact sheet.

Here is more information about the HCAHPS Survey.


A New Set of Tools Helps Improve the Discharge Process

CMS has discharge planning standards in the hospital conditions of participation. These start at tag number 799 and go to tag 843. These were completely rewritten and went into effect July 19, 2013, and went from 24 to 13 standards. CMS then finalized the discharge planning standard on Nov. 26, 2014. This will result in an increased focus on discharge planning for hospitals having a validation or certification survey. There are also a significant number of deficiencies in the discharge planning process. CMS now publishes these on a quarterly basis. In the April 15, 2015, report there were 414 deficiencies. Also, hospitals are financially penalized by CMS for having a higher than average readmission rate.

The American Hospital Association has released a set of tools to help improve the hospital discharge process and transition in care process. The resources include case examples from five different hospitals. Each hospital is unique and what processes work for one hospital but not necessarily work for all hospitals. Hospitals should evaluate their specific data in designing the discharge process. The discharge planning tools focus on assisting physicians and staff to optimize a patient’s health as they plan the discharge process from hospital to home. The document is 32 pages and titled “Private-Sector Hospital Discharge Tools: Samples of Hospital Discharge Planning Tools that Strive to Improve Transitions to Post-acute Care and Reduce Readmissions.”

There currently is not a standardized hospital discharge tool. However, HHS has developed a standardized patient assessment tool. This includes the Continuity Assessment Record and Evaluation Tool and the B-CARE tool. However, this tool does not assist in determining the best setting for the patient to go to when discharged from the hospital. Hospital discharge planning tools differ from patient assessment tools. This report focuses on the discharge planning process.

The AHA resource is available here.

The current discharge planning standards are here.

The CMS hospital discharge planning worksheet is here. To find it quickly, scroll down to Nov. 26, 2014.

The CMS quarterly deficiency reports are here.

The B-care tool information is here.


CMS Restraint and Seclusion; the Most Problematic of All of the CMS Standards

Hospitals must ensure staff understands the definition of what constitutes restraint or seclusion. Remember, it’s not the thing that constitutes a restraint, but its effect on the patient.

If the nurse puts up all four side rails and the patient is not able to lower them, then this constitutes a restraint. If a physician or practitioner orders that all four side rails be up, the nurse should clearly document if the patient is able to lower them without assistance and exit the bed. The same is true of a geri chair. If the patient can exit the chair when they want, then this would not be a restraint.

Make sure the policy includes and staff is aware of what is not a restraint. Forensic restraints such as handcuffs, shackles or other restrictive devices applied by the police or other law enforcement are not restraints and this should be stated in the hospital policy. Orthopedically prescribed devices are not a restraint and could include a cast, double Shantz dressing, surgically dressing or protective helmet. Physically holding down a child or patient for routine physical exams or tests for medical reasons is not a restraint. An example would be holding a child while doing a lumbar puncture or using a papoose board while suturing.

However, a therapeutic hold on a child who is throwing things and acting out or a behavioral health patient would be a restraint. There is an exception for the narrow carts used in places like the emergency department or post anesthesia care unit (PACU). These carts are narrow and usually have one solid side rail and it is necessary to sometimes put these up for patient safety to prevent the patient from falling out of the cart.

Postural supports are also not a restraint. The patient is having knee surgery in the operating room so the knee is extended or the patient is in radiology having a knee MRI. An IV that is not tied or attached is also not a restraint. If a patient comes to the PACU still intubated this is not a restraint and is considered a continuation of the surgery.

The following recommendations will help prevent hospitals from receiving a deficiency in the area of restraint and seclusion:

  • Document the reason for the restraint. The state law determines who is an independent licensed practitioner (LIP). CMS allows physicians and other LIPs to order restraint and or seclusion. Restraints are generally ordered if the patient is a danger to themselves or others. This includes the need to prevent the patient from removing vital equipment or the lack of understanding of safety directions.
  • Alternatives to the use of restraints should be considered. One hospital uses low beds and has padded mats on the floor instead of restraining the patient. Another hospital uses a sitter. One hospital found that by using a plastic dome over the IV and using an elastic sleeve they did not need to use soft wrist restraints on the patients who were pulling out their IVs.
  • It is important to document the order in the chart. Restraints can be ordered by the physician or LIP, which includes licensed residents. The state determines who is a LIP, such as a nurse practitioner. If an order for two soft wrist restraints is written and later the patient needs ankle restraints, another order must be received. If the order is received by an LIP, then make sure the attending physician is notified as soon as possible. This should be documented in the medical record.
  • There are no PRN orders but the three exceptions recognized by CMS. This includes a patient with a repetitive self-mutilating behavior such as Lesch-Nyhan syndrome. A physician could enter an order that when patients are out of bed they be placed in a Geri chair. If the patient can’t get out of the Geri chair, then it would be a restraint. If the doctor writes to put up all four side rails and then if the patient cannot lower them, it would be a restraint.
  • There should be a plan of care for all admitted patients. If restraints are used, then the plan of care should be amended to include this.
  • The restraint should be removed at the earliest time. A trial release is seen as a PRN order and is not permitted. A temporary release is allowed such as releasing the restraint while feeding the patient, doing range of motion, or toileting the patient.
  • The patient should be reassessed according to the hospital’s policy and procedure. CMS does not specify any time frames such as every 15 minutes for patients who are violent or self destructive or every two hours for non-violent patients.
  • Hospitals should document the care given to patients in restraints and or seclusion. This may include fluids offered, toileting, positioning, vital signs, skin integrity assessment, patient behavior, and interventions used.
  • Restraints should be used as directed. The manufacturer’s directions should be followed. Hospitals should follow any state law or standards of care.
  • Patients who are violent should have a one hour face-to-face exam. These should be done by staff that is competent. Hospitals may want to consider having a form to collect the information required by CMS. This includes the patients’ reaction to the intervention, their medical and behavioral health history, need to continue, review of systems, history, and use of drugs or current medications. Time limited orders should be followed. Orders for an adult patient must be renewed every four hours. The practitioner needs to rewrite the order every 24 hours, not every calendar day, when a face-to-face assessment is done.

The hospital needs a policy and procedure and all the above information should be contained in the policy. The surveyor may look at the use of restraint and or seclusion to make sure it is consistent with the policy. The policy should be reflective of the CMS restraint standards and any specific state law requirements.

There is a long list of things that must be in the staff education. The policy should include what categories of staff are responsible for assessing and monitoring the patient. Staff members who are able to remove or apply restraints should be educated on their role. Staff in radiology or ultrasound technicians may need to move the patient onto a cart or table and then reapply them.

Hospitals should be aware of when a report is required to be made to CMS. If the patient dies in either one or two soft wrist restraints, that does not cause the death; the hospital must document this on an internal log and note in the chart that the internal restraint log has been completed. The internal log must include the patient’s name, date of birth, date of death, attending practitioner, medical record number and diagnosis.

Otherwise, if the patient dies in restraints within 24 hours of being in a restraint or if the restraint causes the death within seven days it must be reported on a form and submitted to CMS regional office. It should be reported no later than the close of business the next day. The form is available here on the CMS website.

A copy of the restraint standards can be located here on the CMS website under Appendix A. The manual was updated April 1, 2015.


New [WEBINAR] Series:
The CMS Manual for Critical Access Hospitals: Everything You Need for Compliance





JUNE 2015

6/2/15 - 1.5 CNE
Grievances and Complaints:
Compliance with CMSand TJC Standards

6/3/15 - 1.5 CNE
The Final CMS Worksheet
on Infection Control

6/9/15 - 1.5 CNE & 1.5 CME 
Restraint And Seclusion:
The Most Problematic Of All CMS Standards

6/10/15 - 1.5 CNE
New CMS QAPI Standards and
Revised QAPI Worksheet

6/16/15 - 1.5 CNE
Hospital Utilization Review Programs:
Current CMS CoPs

6/23/15 - 1.5 CNE
Contracted Hospital Services:
Certifying Compliance with CMS, TJC & DNV

6/24/15 - 1.5 CNE
The New CMS Worksheet and Discharge Planning Standards 

6/29/15 - 1.5 CNE
Ensuring Compliance with CMS Anesthesia Standards


7/14/15, 7/22/15 & 7/29/15 - 6 CNE & 6 CME
Regulations and Interpretive Guidelines for CAHs, Nursing and Drugs at Critical Access Hospitals & Records and Swinging: All the Requirements your CAH Needs
7/15/15 - 2 CNE
Proposed Rules on Stage 3 & 2015 Edition Certification Criteria from the HHS
7/16/15 - 2 CNE
Joint Guidance for Hospital and Health Care Board Compliance
7/21/15 - 2 CNE
TJC Leadership Standards Essential to Engage Staff, Support Operations and Provide Quality Care
7/28/15 - 1.5 CNE
Sentinel Safety Standards
8/4/15 - 2 CNE
Nursing Law Update: New MRI Standards & CMS Updates
8/11/15 – 1.5 CNE
CMS Telemedicine Standards
8/25/15 - 2 CNE
CMS Requirements on Order Sets, Protocols,
Preprinted and Standing Orders