• TS: – CMS: What’s New for Deemed Status Hospitals in 2013 [REF: JCSC, LDR, MDx, P&T, Phrm, RNx] The Source, December 2012, Vol 10, #12, Pg 10 [®]
This past May, CMS updated its Conditions of Participation (CoP) for hospitals and within a few months (became effective in July) TJC updated and aligned its standards accordingly. This article provides useful insight into and briefly reviews the TJC implications of the following selected changes:
- Re: Standing Orders – (Key Def: are those care pathways that a nurse can initiate prior to a patient-specific order from a physician) New EP 15 for MM.04.01.01 more specifically requires review/approval of such orders by the medical staff, along with nursing and pharmacy leadership. They must be evaluated for consistency with “nationally recognized/evidence-based guidelines”, periodically reviewed and properly authenticated. TIP: If you utilize standing orders, have your P&T Committee (with attending MD, RNx and Director of Pharmacy) annually review your policy for continuation/modification, consider an updated literature review and document the process in Minutes.
- Re: Leadership Requirements – CMS changes included an expansion of its concept of the medical staff to include APRNs, PAs and Pharmacists . TJC standards already permitted this eligibility. However, LD.01.05.01, EP 7, has been revised to align with CMS permission for Podiatrists to lead the medical staff. LD.04.01.05, EP 8 was revised to allow organizations to have more than one director over outpatient services. TIP: New Medical Staff leadership option that may be useful to small hospitals
- Re: Verbal Orders – CMS (and therefore TJC) has removed the 48-hour time limit on verbal order authentication, BUT organizations will still be held accountable to any relevant state law or regulation, including the 48-hour window if it is on your state’s books. TIP: Know your state’s requirement and review your policy/practice to ensure compliance.
- Re: Patients Self-Administering Medications – CMS now permits patient self-administration of medications which makes it consistent with TJC standard MM.06.01.03. TIP: See Complying with MM.06.01.03 above.
- Re: Restraint-Related Deaths – Although TJC has always required restraint-related deaths to be reported to CMS, there is now a more specific expectation for those deaths occurring while a patient is in soft, two-point wrist restraints, to be recorded within 7 days in a log of some kind that can be made available to CMS or TJC surveyors upon demand. The article reports a revision to PC.03.05.19 EP3 to reflect this. [Note: Although specifically referenced in the article , we have been unable to find this standard and/or EP in current manuals] TIP: Make sure any restraint-related deaths are properly reported and logged/documented in a readily retrievable format.
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