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Critical Access Hospital Changes

CMS revised the Critical Access Hospital Conditions of Participation (COPs) effective April 7, 2015, changing about one-third of the hospital manual.

Most of the changes are similar to, or a shortened version of, the CoPs for hospitals under Appendix A. This is helpful for hospitals in systems because there are now fewer variations between programs. It should also be easier for surveyors since many of the sections are now more similar. CMS rewrote all the sections on pharmacy, outpatient, contracted services, infection control, nursing, dietary, rehab, and drugs and biological.

Here are details on four major changes to the CAH manual.



CAH Dietary Standards Have Changed

The dietary guidelines for CAHs were completely rewritten by CMS, starting at tag 279. If the CAH furnishes inpatient services, which most do, it must put procedures in place ensuring the nutritional needs of patients are met. A CAH is not required to prepare meals itself and could obtain the meals under contract. Most CAHs find it easier to prepare the meals themselves.

An order from the patient’s physician or other practitioner is needed for the patient’s diet. The hospital medical staff and board is also permitted to credential the dietician to order diet under tag 279. Hospitals cannot allow dieticians to order the patient’s diet but must include a policy and the person must be credentialed and privileged C&P. Diet includes therapeutic diet, supplemental feedings, TPN, or associated lab tests. The state must also not prohibit this practice. In states that have a qualified nutrition specialist, they can also be C&P to order diet. The CAH must follow the provider’s order.

The director of dietary services must be qualified based on education, experience, specialized and training. The director must be licensed and or registered if state law requires it.

The new standards also refer to swing bed patients, which most CAHs have. The dietician needs to ensure swing bed residents maintain acceptable parameters of nutritional status, such as maintaining their weight and an appropriate protein level.

The hospital must follow recognized dietary practices. Take, for example, the National Academy of Medicine’s Food and Nutrition Board’s Dietary Reference Intake. It references four values including the recommended dietary allowance, which is the average dietary intake of nutrition for healthy people.

The Department of Agriculture and the Department of Health and Human Services publishes the Dietary Guidelines for Americans every five years. A draft of the 2015 edition is available here.

Therapeutic diets help to meet the patient’s nutritional needs, such as the 2 Gram Low Sodium diet or a 1500 Calorie ADA diet. Patients must be assessed to determine if they need a therapeutic diet or if they have other nutritional deficiencies. The assessment may be included in the patient’s care plan and may mention the need to monitor food intake, I&O, lab values or daily weights.

Often during the nursing admission assessment, a nutritional screen is done. The results may prompt a consult with dietary. CMS lists some situations that may prompt a more comprehensive nutritional assessment by the dietician, including:

  • Patient has a medical or surgical condition that interferes with their ability to digest or absorb nutrients like a gluten problem or Crohn’s disease.
  • Patients have signs and symptoms indicating a risk for malnutrition such as anorexia nervosa, bulimia, electrolyte imbalance, or end stage renal disease.
  • Patients have a medical condition that adversely affects their intake and so they need a special diet such as heart failure, diabetes, or renal disease.
  • Patients may be receiving artificial nutrition like tube feeding or TPN.

Information on the IOM’s DRI or Dietary Reference Intake is available here.


Nursing Services Upgraded to Prevent DeficienciesHRM for Compliance Mentor

The April 7, 2015, CAH manual includes rewrites of all the nursing interpretive guidelines, starting at tag 294. Nursing services must be organized to meet the needs of the patients. The hospital must have a chief nursing officer who is an RN responsible for the development of the nursing policies and procedures. Nursing staff should always be aware of the hospital’s policy. Be warned: Surveyors will hold staff accountable.

There must also be a nursing care plan as part of the permanent medical record. Nursing can do it as part of the interdisciplinary plan of care.

Any agency nurses must be oriented and supervised. Hospitals have flexibility on this. Some have computerized educational programs, others information on a CD, and others have a self-assessment learning packet. The surveyor may interview nurses to determine how all the staff, including agency nurses, is oriented. The surveyor may look at staffing plans.

There is a separate section on drugs and biologicals, but the nursing section contains interpretive guidelines on drugs and IVs. CMS requires an order for drugs and biologicals that is not only signed but dated and timed. Orders must be written and drugs administered should be consistent with the acceptable standard of care. CMS specifically mentions organizations such as the Institute for Healthcare Improvement, the CDC, the Institute for Safe Medication Practices, U.S. Pharmacopeia, Infusion Nurses Society, and the National Coordinating Council for Medication Error Reporting and Prevention.

The guidelines must ensure compliance with standards for self-administered medications, staff training, basic safe practices, timing of medication, standards for IV medication, documentation, and assessment of patients receiving medications. Appendix A defines many of these areas in detail and includes a section for ensuring safe opioid use. Staff should be familiar with the opioid policy, how to monitor patients safely on opioids, and how frequently to monitor, including vital signs, pulse oximetry, sedation scale evaluation, and end tidal CO2. There is also a detailed section on safe administration of IVs and blood.

Staff must be trained on the policy and it must be approved by the Medical Executive Committee. Staff should also ensure all IVs and other lines are going at the correct amount including IV pumps. Patients must be told to notify a nurse immediately if they have any trouble breathing or if they think they may be having an adverse reaction to the medication. Hospitals may want to consider using a special assessment sheet when opioids are prescribed.

This section also includes requirements for verbal and standing orders, a longtime area of deficiencies. Staff should not take a verbal order unless necessary. Verbal orders should be documented in the medical record by the person taking the order, then signed and dated. The practitioner giving the order must sign the order off promptly.

The hospital is required to have a policy for verbal and standing orders.

Hospitals should also review the Final National Action Plan for ADR Prevention, which includes a section on safe opioid use.


An Update on CAH Safe Medication Practices

A recently CMS-rewritten infection control standard for CAHs addresses safe medication practices, which are currently being hit very hard during surveys.

If the medication is available as a single dose, it should be purchased. If the medication is only available in a multi-dose vial, then the nurse should use the multi-dose vial on one patient and never take it into the patient’s room. The expiration date should be marked on the vial.

CMS also has a section in the infection control worksheet on safe injection practices. Even though surveyors are using the worksheets in CAHs, hospitals should still carefully review this worksheet to ensure compliance. It’s an important self-assessment tool that should not be overlooked.

Safe medication preparation starts at tag 278. Medications should be prepared in clean areas. Proper hand hygiene should be performed before handling any medication. The rubber septum should be disinfected with alcohol before piecing it. Standard practice is to disinfect it with alcohol for 15 seconds and allow to dry. Aseptic technique should be used when preparing medications and administering injections. Never administer medication from the same syringe to more than one patient, even if the needle is changed. Never enter a vial or IV with a used syringe or needle. Single-dose vials and IV bags can be used only on one patient. A mask must be worn when placing a catheter in the epidural, spinal or subdural area.

The 10 CDC safe practices can be found in the Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

All CMS memos can be found here.


Rehabilitation Therapy Updated for Consistency

The rehab standards were omitted from the CAH in June 2013 when several changes were made to the manual. The revised manual contains a section on rehab beginning at tag 299. Rehab services must be provided by qualified staff, including physical therapy, occupational therapy, and speech-language pathology. Hospitals are allowed to have up to a 10-bed separate unit for both rehab and behavioral health and the standards in Appendix A must be followed. The rehab standards are consistent between the two manuals.

Rehab is on optional services so a hospital does not have to provide it. It can be provided directly or through contracted services. Hospitals that contract this out should make sure the contracted service is assessed through the contract management standards.

There must be an order for the rehab. The hospital must have a rehab policy and procedure and the requirements in this section should be part of the rehab policy. The care must be consistent with the standard of care so hospitals should be familiar with positions statement promulgated by organizations like the American Physical Therapy Association and the American Occupational Therapy Association.

The patient must have a plan of care, which must be outlined before treatment begins. It can be done by an MD/DO, physical therapist, occupational therapist, or speech-language pathologist. The plan of care must prescribe the type, amount, frequency, and duration.


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