Nursing: CMS CoP Standards for Hospitals (W6005)-Nursing: CMS CoP Standards for Hospitals Recording

Video Transcription

Video Summary

The session introduces Laura Dixon, an RN and attorney with extensive risk management and patient safety leadership experience, who presents an overview of CMS nursing-related requirements for acute-care hospitals and critical access hospitals (CAHs). She frames common CMS deficiencies such as lack of RN supervision, failure to follow physician orders, poor insulin administration practices, inadequate monitoring of restraints/seclusion, weak abuse follow-up, incomplete fall prevention, and outdated or missing care plans.<br /><br />Dixon highlights CMS guidance affecting nursing, including ligature-risk mitigation (patient assessment, trained staffing/monitoring, and environmental risk assessments) and strengthened discharge planning expectations (complete medication reconciliation, durable medical equipment needs and training, skin status, behavioral health/substance use needs, and incorporating patient goals). She also reviews non-discrimination and language-assistance requirements under OCR/Section 1557, emphasizing free interpreter services, signage/taglines, and complaint-handling processes.<br /><br />Core nursing Conditions of Participation include organized 24/7 nursing services with at least one RN furnishing or supervising care, CNO leadership authority, competency/credential verification, integration with QAPI, and adequate staffing based on acuity and unit layout. She discusses outpatient areas where an RN may not be required if criteria and alternate staffing/emergency response plans are defined and reviewed.<br /><br />A major portion covers medication administration: compliant orders (including standing and limited verbal orders), “five rights,” safe injection practices, beyond-use dating responsibilities, medication timing categories (time-critical vs non-time-critical), monitoring for adverse effects (especially high-alert meds/opioids), blood transfusion verification and monitoring, and controls for patient self-administration/home medications. She concludes with CAH-specific parallels and notes many other CMS chapters also impact nursing practice.

Keywords

CMS nursing requirements

acute-care hospital Conditions of Participation

critical access hospital (CAH) compliance

RN supervision deficiencies

discharge planning medication reconciliation

ligature risk mitigation

restraints and seclusion monitoring

Section 1557 nondiscrimination language assistance

interpreter services and complaint process

QAPI integration nursing services

medication administration five rights

safe injection practices beyond-use dating