CMS Hospital Improvement FINAL RuleS: Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI, and more

CMS has finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This include changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion.

Most have had an effective date of November 29, 2019 with two exceptions. The normal implementation date is 60 days but Critical Access Hospitals will have 6 months to implement an antibiotic stewardship program and 18 months to implement a QAPI program since their QAPI requirements were completely written.

It will also require all hospitals to have an antibiotic stewardship program and what the program should include. Currently, only 68% of hospitals have an antibiotic stewardship program. Also a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.

OCR has found that 1 in 10 HIPAA complaints surround the patient access to medical records. CMS wants to implement requirements contained in another federal law, known as Section 1557 of the ACA, in the hospital CoPs. This way they could also enforce it or can refer the matter to the OCR. Join this informative webinar by Hospital expert Sue Dill Calloway, RN, MSN, JD as she discuss all significant changes to the hospital (CoPs) and make you prepared to comply with federal regulations.

Session Objectives

  • Recall that hospitals have requirements in the CMS CoPs on antimicrobial stewardship program

  • Discuss that CMS change the term LIP (licensed independent practitioner) to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments if allowed by the hospital

  • Describe that the hospital must have policies that describe which outpatient areas require a RN

  • Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths

Session Agenda

  • Introduction

    • Interpretive guidelines and survey procedure to be issued

    • How to get a copy of the CoP manual, survey memos, etc.

    • Why revise the CoPs

  • Psychiatric Hospitals

    • Non-physicians writing in progress notes

    • How often progress notes must be written

  • Emergency Preparedness

    • Staff training every two years; Exercises twice a year

    • EP policies and procedures; Emergency plan

  • H&P Changes

    • When is a H&P required

    • Assessments instead in healthy outpatients

    • Medical staff policy requirements; Considerations

  • Patient Rights and Medical Records

    • Restraint changes

    • Change from LIP to licensed practitioner (LP)

    • Physician Assistants (PAs) to order and evaluate

    • Non-discrimination under OCR 1557

    • Medical Records section was not implemented

  • QAPI

    • Quality indicator data including patient care data

    • Medicare Quality Reporting Data

    • Hospital readmission data

    • Hospital acquired conditions (HACs) and 5 changes

  • Nursing Services and Outpatient Departments

    • Staffing-adequate number; Supervisory staff

    • Need to respond immediately when needed

    • Nursing care plans; Policies and procedures

    • CNO must evaluate nursing staff including agency staff

    • All outpatient departments must identify if RN must be present

    • Outpatient policy required

    • P&P must be reviewed by MEC

    • Orders for drugs and biologicals

  • Look Back Program and the Lab

    • Notification of tainted blood

    • Patient notification process

    • Time frame for notification

  • Four swing bed changes

    • Dental

    • Activity program and assessment and plan of care

    • Social worker; Residents performing services

  • Infection Control and Antibiotic Stewardship

    • Hospital wide surveillance

    • CDC outpatient assessment tools

    • Following national recognized standards and best practices

    • Infection control hospital wide QAPI program; QAPI leadership

    • Infection control program and policies requirements

    • Qualified infection preventionist; Tracking all infections

    • Requirements for the antibiotic stewardship program; CDI

    • Antibiotic stewardship policies

    • Competency based staff training

    Who Should Attend?

    Chief medical officer, QAPI director and staff, Health information management, Board members, Infection preventionist, Antimicrobial stewardship team members, Patient safety officers, Regulatory and compliance officers, Physician assistants (PAs), Pharmacist, Chief nursing officer, Nurses, Nurse educators, Patient advocate, Risk management, Hospital legal counsel, MEC chair, and anyone involved in implementing the hospitals CoPs.

    Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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Webinar Information

Date / Time : 06 Feb 2020 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

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Contact 1888-437-7218 or
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Speaker Detail

Sue Dill Calloway RN, Esq. CPRHM CCMSCP AD, BSN, MSN, JD

Alt Text Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for readmore...


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Webinar Information

Date / Time : 06 Feb 2020 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at