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CMS Proposed Changes to the Hospital CoPs

Nursing, Medical Records, Infection Control, and QAPI Changes

The Centers for Medicare & Medicaid Services (CMS) is making some important changes to hospital Conditions of Participation (CoPs).

CMS outlined its proposed changes to nursing CoPs and clarified distinctions between inpatient and outpatient status in its proposed rule, published June 16 in the Federal Register.

Some of the proposed CoP changes include the following:

  • CMS clarifies that a current nursing care plan must be maintained with evidence of patient goals and reassessments. All nurses, including agency nurses, must follow the hospital policies and procedures. The chief nursing officer (CNO) must provide supervision and evaluations of all clinical activities for agency staff and all nursing staff.
  • To make a clearer distinction between inpatient and outpatient status, CMS wants to ensure a current progress note is placed in outpatient records. There must be a diagnosis in all charges, including outpatient, which must occur within seven days. Complications, hospital-acquired conditions, adverse drug events, and anesthesia adverse events must be documented in the medical record, which also must include discharge summaries and transfer summaries for all patients.
  • Licensed independent practitioners would be changed to licensed practitioners, allowing physician assistants to order restraints and to assess patients who are in restraints.
  • Hospitals must identify which outpatient areas require the presence of a registered nurse, based on patient acuity and services provided in outpatient areas.
  • Patient access to medical records would have to be made within a “reasonable amount of time” upon oral or written request. Generally, patients should receive copies of records within 30 days, with a 30-day extension for some cases.

CMS Nursing CoPs Email Banner Vertical

The comment period on the proposed rule runs until Aug. 15.

AHC Media is offering a webinar on the CMS proposed changes to the hospital nursing CoPs on Aug. 15, 2016 from 1-3 p.m. EDT. For more information, contact customer service at (800) 688-2421 or [email protected].

AHC Media also offers a running webinar series on the current CMS hospital CoPs regulations and interpretive guidelines in addition to many of the proposed changes. The guidelines will be covered in a five-part series, beginning Sept. 19 and running through Oct. 24. For more information, contact customer service at (800) 688-2421 or [email protected].