CAH CoP 2020 Series- Part 1: Introduction, Memos, New Laws, Safe Injections, Advance Directives, Emergency Services, Drugs and Equipment, and Observation

HEALTHCARE Mar 09, 2020 120 minutes
01:00 PM EST 12:00 PM CST 11:00 AM MST 10:00 AM PST

Description:-

At the conclusion of part one, participants should be able to:

  • Describe that CMS requires that the board must enter into a written agreement if the hospital wants to enter into a  telemedicine contract
  • Discuss that CMS has a list of emergency drugs and emergency equipment that every CAH must-have.
  • Recall that the length of stay in the CAH should not exceed 96 hours on an annual average basis.
  • Discuss recommendations to do a gap analysis to ensure compliance with all the hospital CoPs.

Session Agenda:-

Introduction

  • History
  • Final changes: Discharge planning and the Hospital Improvement Rule
  • Most recent changes 
  • CMS memos
  • Insulin pen, safe injection practices, deficiencies, reporting to PI, final three worksheets, texting, revised complaint manual, humidity in the OR, OPO contracts, equipment maintenance, EBOLA, CRE, ligature risks and scopes, glucose meters, etc
  • ISMP IV Push Guidelines
  • CAH problematic standards
  • CAH Resources
  • Conditions of participation
  • CMS 3 Worksheets
  • How to find manual, survey memos, and changes
  • CMS websites
  • Copies of documents by the surveyor
  • How to locate changes
  • Rehab or Psych distinct unit standards
  • CMS Survey and Certification website
  • Visitation 
  • Telemedicine standards

 

Survey Protocol

  • Introduction
  • Tasks in the Survey Protocol
  • Survey Team

 

Regulations and Interpretive Guidelines for CAHs

  • Swing bed module
  • Compliance with Federal, State and Local Laws and Regulations
  • Licensure of CAH
  • Licensure, Certification or Registration of Personnel
  • Status and Location
  • Location Relative to Other Facilities or Necessary Provider Certification
  • Compliance with CAH Requirements at the Time of Application Agreements
  • Agreements with Network Hospitals
  • Agreements for Credentialing and Quality 
  • Advanced directives
  • Emergency Services, respiratory policies
  • ED staffing
  • EMTALA
  • Equipment, Supplies, and Medication
  • Blood and Blood Products
  • Staffing/Personnel
  • Coordination with Emergency Response Systems
  • Number of Beds and Length of Stay
  • Observation, the two-midnight rule
  • Number of Beds
  • Length of Stay
Presenter BIO

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 current board member.  She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer.  She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association.  She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years.  She does frequent lectures on legal and risk management issues and writes numerous publications.

Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics.  She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year.  She was the first one in the country to be a certified professional in CMS.  She also teaches the course for the CMS certification program.

She also writes many articles for Briefing on the Joint Commission. She also writes articles on ambulatory surgery and present educational programs on ambulatory surgery issues. She was affiliated with Mount Carmel College of Nursing as an adjunct nursing professor for over seventeen years. She was also a trial attorney for eight years defending nurses, physicians and healthcare facilities.

She has been employed in the nursing profession for more than 30 years.  Ms. Calloway has legal experience in medical malpractice defense for physicians, nurses and other health professionals.  She is also certified in healthcare risk management by the American Society of Healthcare Risk Managers.

Ms. Calloway received her AD in nursing from Central Ohio Technical College, her BA, BSN, MSN (summa cum laude) and JD (with honors) degrees are from Capital University in Columbus.  She is a member of many professional organizations. She has a certificate in insurance from the American Insurance Institute.

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