Clarifying the Confusing CMS Hospital Surgery, PACU, and Anesthesia Standards

181 Pages·2014·5.29 MB·English

Clarifying the Confusing CMS Hospital
Surgery, PACU, and Anesthesia Standards
Thursday, August 28th, 2014
Speaker
 Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
 AD, BA, BSN, MSN, JD
 President of Patient Safety and
Education Consulting
 Board Member
Emergency Medicine Patient
Safety Foundation
 614 791-1468
 [email protected]
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Learning Objectives
1. Recall the CMS policies and procedures related to
anesthesia services and surgery.
2. Discuss the 48-hour requirements for post-anesthesia
evaluations.
3. Explain what must be included in the OR register.
4. Explain new and revised standards, regulations, and laws
put forth by CMS, TJC and the federal government.
5. Evaluate compliance requirements and penalties.
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Author of Book on the CMS Anesthesia Standards
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You Don’t Want One of These
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The Conditions of Participation (CoPs)
 Many revisions in past to respiratory and rehab
orders visitation, IV medication blood, and opioids,
anesthesia, pharmacy, timing of medications,
confidentiality & privacy, PI, luer misconnections,
discharge planning and equipment maintenance
 Manual updated June 6, 2014
 First regulations are published in the Federal Register then
CMS publishes the Interpretive Guidelines and some have
survey procedures 2
once a month
 Hospitals should check this website for changes
http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR
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2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
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CMS Survey and Certification Website
www.cms.gov/SurveyCertific
ationGenInfo/PMSR/list.asp#
TopOfPage
Click on Policy & Memos
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CMS Survey Memos Issued
 IV, Medications, Opioid Mar 14 and effective June 6, 2014
 Emergency Preparedness Checklist Feb 28, 2014
 Emergency Preparedness Draft Changes Jan 3, 2014
 Hospital Equipment Maintenance Dec 20, 2013
 Privacy and confidentiality memo on March 2, 2012
 Complaint manual updated April 19, 2013
 Access to hospital deficiency data March 22, 2013
 Use of insulin pens issue May 18, 2012
 Single dose June 15, 2012, Humidity in OR 2013
 Discharge planning rewritten May 17, 2013
 Reporting to internal PI March 15, 2013
 Luer Misconnections March 8, 2013
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Subscribe to the Federal Register
http://listserv.access.gp
o.gov/cgi-
bin/wa.exe?SUBED1=
FEDREGTOC-L&A=1
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