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All facilities accredited by TJC, AOA, CIHQ, and DNV Healthcare must adhere to the CMS CoPs. This 525-page manual contains interpretive guidelines, policies, procedures, and standards that must be followed for all providers treating patients hospitals or any hospital-owned departments.
Part I of the series will provide an overview the CMS survey and interpretive guidelines.
CMS Survey Process
|- Introduction||- 2018 proposed changes||- Revised worksheets|
|- Memo changes||- Survey protocols||- Survey team|
|- Required education||- Recent changes||- 2015 & 2016 revisions|
|- Complying with the law||- Order sets, protocols & standing orders||- Deficiency memos|
Board & CEO
|- Board requirements||- MS by-laws||- MS appointment|
|- Credentialing & privileges||- TJC tracer on C&P||- Medical staff|
|- Single vs. unified MS||- Recent changes||- Telemedicine|
|- CEO requirements||- Patient care||- Planning & budgeting|
|- Contracted services||- Emergency services||- Privileging staff|
Medical Records (Health Information Management)
|- Confidentiality of Substance Use Disorder Patient Records Rule||- Confidentiality of records||- Mandatory informed consent|
|- 2018 proposed changes||- Content of records||- Signature stamps|
|- Organization & staffing||- Verbal orders||- Authentication|
|- Discharge summary||- H & P||- Optional elements|
Anyone involved with or interested in compliance regulations and standards, including but not limited to: CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Board Members, Clinic Managers, Outpatient Directors, Lab Directors, Compliance Officers, CMS Liaisons, TJC Liaisons, Registration Staff, Safety Officers and Staff, Pharmacy Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Legal Counsel, Behavioral Health Staff, Psychiatry Staff, Social Workers, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.