I would like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region, Patient Safety, and Risk Management for the Doctors' Company in Napa, California. In this capacity, Laura provided patient safety and risk management consultation to the physicians and staff for the Western United States. And as a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura. We invite you to go ahead and kick us off and get us started. Okay, and thank you everyone. And I hope you can hear me. I'm having some challenges with my headset, but it seems to be working now. So I want to do again, pardon me? We can hear you well. You sound good. Thank you. All right. Well, let's go ahead and just kick it off and get started. This is my normal disclaimer that the information provided today is informational, educational. It is not intended to be legal advice nor establish an attorney-client relationship. Please reach out to your in-house counsel, legal representative for any particular advice, especially as it relates to any state law. Well, I want to start off with, of course, why we are here today. And the first one, well, nobody wants to get that notice of deficiencies after they've come in and done a survey. And then, of course, no facility, no provider ever wants to get that notice of termination from CMS and the Medicare and Medicaid agreement. These are pretty serious events when those do happen because that's a huge financial hit for any hospital or any facility. Overall, how does this whole thing work? The regulation, the law, and we're going to be touching on those. Those are published in the Federal Register. Then CMS, they put out what's called a transmittal, and it tells their surveyors, hey, this is what's new. This is the change that's coming up. They are then tasked with developing guidelines and survey procedures. And the guidelines are really a lot of information for those surveyors on this is what we expect. This is the rationale behind it. And then, of course, they then have to update the manual itself. Three types of surveys, certification, hopefully you never get a complaint survey, that can kind of make your day a little miserable, and then the validation survey. I've noticed that CMS is starting to having their state agencies come around more frequently when it happens to be a deemed status. They're just making sure that those deemed status organizations, Joint Commission, DNV, they're stepping up and making sure that what they're reviewing and expecting is the same as what CMS would have. How do we keep up with these changes? If you're in compliance, for sure, I urge you to subscribe to the Federal Register. That will keep you up to speed on the new regulations as they come out. You also want to make sure you have the current manual. The first one came out in 86, multiple updates since then. The last one for acutes came out in July of last year. Critical access, yours hasn't come out just yet. The last update they made was in 2020. I'm hoping they start to come around and update yours because there have been some changes with that manual. They split out the regulation and the section into tag numbers. That's how they would issue a deficiency. Of course, if there is a new manual, check the Terrance Middle page. That's an easy way to find out what's been revised, what's new, and what's been deleted. You might want to also check that certification site monthly. That's where they post all of their memos. There's what it would look like when you're signing up to get the Federal Register. Here's the appendix for the manual. What we're going to be talking about today is Appendix A's and Appendix W, acute and critical access hospitals in particular. There's some overlap in what we're going to be talking about. A little bit of difference, so that's why I wanted to separate them out. Also keep in mind and have handy Appendix Q. That's immediate jeopardy because if CMS or one of the deemed status find an issue that jeopardizes the health, safety, well-being of patients, they could issue immediate jeopardy. Higher standards, much more rapid turnaround that's expected for any changes that you're going to make. Here just happens to be the table of contents for acute hospitals. Again, you will see it was last revised, July of 2023. An easy way to hit those transmittals, by the way, the lettering, the blue lettering will take you right to that when you get in there, and that's what that transmittal page looks like. It will give you what the updates happen to be, when it was, the issue date, and that's an example of exactly what it looks like. On the right-hand side, you will see the revised, the new, or the deleted. So again, easier way to find out what's been changed. Here is the link or the page for the memos. It used to be you had to go a couple times, hit that posting date to get the most current. Now they go chronologically. They updated the site late last year, and it's much more user-friendly. It really is. Once you open it, you're going to see what's changed, and that's just an example of what one looks like. By the way, we're touching on this particular memo today during the program because it talks about ligature risk and how we keep patients and staff and others safe. Deficiencies. Why are we here? I mentioned you don't want to get that deficiency. We can access that information from CMS. Has the acute and critical access hospitals. It is updated quarterly. I want to give you a heads up. They updated this whole site, again, late last year, and some of the data is now only available from October of 2018. Anything else prior to that is gone. I understand why they would have done that because it's almost not relevant anymore, but the data is gone, unfortunately. I have here on slide number 19 how you would get to there. Here's the link. Scroll to the bottom. Full text statements, and you get a very large Excel document. Now, I always filter it by deficiency tag number, which you can do. You may want to do it by your hospital. You may want to do it by your state. That's another way to look at it, but if you are doing it by tag numbers and you want to focus on a particular tag number, you will have to put the letter and then the four-digit number. Otherwise, you will get the wrong information. I always suggest you might want to check out the Healthcare Association, hospitalinspections.org, because they collect that data and give you much more information. Once you're in the site, you will want to find where your state is, and then it pulls up all the hospitals. This is nice because it gives you much more deep dive into a particular facility. I always pull up just one of my older ones to see how they're doing. Well, kind of a dip in some of their deficiencies, but again, you get much more information in that report. It's not a very simple, based upon review of records, this is what we didn't see. Here it goes into much more detail, and you can really get more references on what they worked on. So, the deficiencies for nursing and the areas we're covering today, you can see a lot of them talked about the services themselves and supervision of nursing. That was one of the higher areas of deficiencies. And then we have administration of medications. There will be a lot of discussion on this, because of just how much nursing is involved in doing that. Care plan, also another biggie. And then they start to taper off on what's going on, for a total of almost 9,000 deficiencies. And again, just since 2018, critical access once I get there. Well, overall, there were changes back in 2020 to the nursing section through the hospital improvement. What they did was, number one, they clarified the need for a nursing supervisor in certain areas. Do you need it or do you not need it? Number two, sufficient staff. We need to have enough staff take care of patients and do it safely. And then finally, the big issue of immediate availability of an RN at the bedside. It's that one word, bedside, that they omitted. Because it really referenced or made it clear to only reference inpatient. Well, that's not the case. Because if you do participate in Medicare and Medicaid programs, you have to meet these requirements. And if you have, say, an outpatient surgery center connected with your hospital, yeah, you'd want an RN, but they're not at the bedside. That's not inpatient. Another thing we have to have is a current nursing plan. That didn't go away. We still have to have one. And how we reassessed the patient, and specifically, what were their goals and treatment preferences when they were getting ready to go home. They also stressed that every nurse has to follow our policy and procedures. Not just your staff, but agency also. Your chief nursing officer, they have to be able to evaluate clinical activities of your staff. Again, agency and other staff. Now, that doesn't mean they can't delegate that. But they have to be able to make sure there are guidelines and what's expected in the evaluation for all of the nurses. Has to have an order for drug, with the exception of flu and pneumovacs. Now you can have protocols to use those and administer those. And verbal orders, they were trying to get rid of them, but they realized that's not going to happen. There are times the providers, the practitioners, they can't be there to write an order. So now they're allowed to use them infrequently. Other changes, you have to have policy and procedures on prohibiting discrimination. We'll talk about discrimination, section 1557. Now, these particular guidelines that I'm talking about, they're not in the conditions of participation. But nonetheless, the Office of Civil Rights and this requirement under the Affordable Care Act, it still applies to nursing and all the healthcare providers. If the surveyor comes in and finds some concerns regarding discrimination, particular say interpreters, they can send that over to the OCR for further investigation. Then we have to talk to the patient, let them know, keep them informed of their right to be free from discrimination. Now we have to be able to tell the patient that. We have to have a policy that lists all the outpatient areas that have to have an RN. These are ones, the policies, they are approved by the CNO. You review them every three years. And what are the criteria for that outpatient area? Now, when you're doing IV therapy, you'd want an RN there. But let's say you're doing maybe some radiation therapy. Do you need an RN? That's up to you. You have to have the policies that describe which areas must have an RN there. And it could also be some of the radiology. All right, a couple of the memos that really hit on nursing. And this is the first of the questions that Lindsey mentioned. Lindsey? Okay, let's get that one up here on your screen. Okay, this says, we have had challenges staffing for patients who may be suicidal or at risk for self-harm. One of the challenges has been finding ligature safe rooms. Yes, no, or not sure. I see several of you putting in your responses. Thanks so much for participating with us. And I know there is some legislation out there right now with the Biden administration where they really want to start increasing funding for behavioral health and the provision of behavioral health services for patients. So this may, you know, the memo that I'm going to show you, I think really started to spark some of that, some of that discussion. And that's now coming out. Absolutely. Okay, we've gotten some good responses. Good. Go ahead and share those results. Okay, yeah. You've had challenges. I'm really, I'm really not surprised. Every hospital. It doesn't matter if you're a 25 bed critical, if you're a real hospital, you're a major university. We seem to have these problems because I don't know if we're just starting to see an uptick in some of the patients or they're now coming in for treatment. Hard to say which one it is. Well, there was an original memo that came back, back in 2018. And it talked about ligature risk in hospitals. They used to say, well, we're not going to do this. We're not going to do this. And they updated this in July last year, and they really reiterated, we want a safe environment so patients don't go hanging themselves. And that really, it not only focuses on the care and safety of the patients, but safety of the staff. By the way, there's no waivers for ligature risk deficiencies. If you're cited, you have to take care of it. You have to provide monthly progress reports if that does happen. So CMS was starting to get some changes and a little bit of confusion and questions constantly coming out on ligature. So they released this memo, again, in July of last year. That's the site on how you would find it. I showed you a picture there at the beginning. And again, it focuses on the care of these patients. There were three main elements that they talked about in order to try and ensure safety as related to ligature risk. Patient assessment, staffing and monitoring, and that can be a big issue in some hospitals, and environmental risk. What are those? Well, of course, the patient assessment, you have to be able to show how you pinpoint those patients who might be at risk for self-harm or harm to others. That can be your staff. That can be visitors. It doesn't have to be just themselves. And then what did you do to minimize those risks following nationally recognized guidelines? They reiterated those risks with ligature, sharps, access to medications, breakable windows, even oxygen tubing to try and hurt themselves. As far as screening and tools, this is indicated that we have to have those appropriate to what your population is. And where are they? What's the care setting? Are they in emergency room? Are they on a medical floor? Are they in a closed behavioral health unit? What's the staff competency in order to assess a patient for ligature risk? We have to screen our patients, of course, all patients in the hospitals and the units, the behavioral health units. Acute care, those who are being evaluated and treated for those conditions as the primary reason for care. And then everyone else, according to what your hospital policy is. So for example, let's say that you have a patient who, you know, says, yeah, it's been a tough year. I've been really down about it. How much assessment would you go into doing with that patient as opposed to a patient who's perhaps had some incomplete suicide attempts in the past? Those would be a little bit higher, or those who are actually admitted because they did have an incomplete suicide attempt. It also talked about our staff, that we have to have an appropriate level of education and training so your staff can identify these patients at risk. And what are the risk factors in that environment? They have to be able to mitigate those items and have those strategies in place. And this is everyone. It doesn't matter if it's your per diem, your agency people, your employee people. It doesn't matter. We have to make sure that their education and training meets those standards. And you are expected to provide it at orientation if you're changing up your policy and procedure, at least every two years after the initial training. On environmental risk, put together a strategy so patients are safe. And that's going to differ according to what's your size and what units is this patient located. And we, of course, want it specific to that patient population. If you have adolescents or if you have children, don't forget them. They can still suffer from self-harm. The assessment must be appropriate to each unit. Again, what do you have in your med-surg unit as opposed to your locked unit? What is the possibility you may take care of a patient who does want to hurt themselves? Working in ICU and CCU, we would get those patients, those who tried to overdose or those who tried self-harm in other ways. What do we have to do in that particular unit to keep them safe while they were there? Again, they reiterated no waivers for the deficiencies. Another memo that came out a little bit nicer, a little bit more cheerful, so to speak, content was discharge planning. Now, this was June of 2023. They reiterated that hospitals, you have to have an effective process. And this process for discharge planning has to focus on what the patient's goals and treatment preferences are. And here's the key, include the patient and their support person in this planning. Because you could easily face a citation if you do not, and you're going to probably upset the family if the patient's just sent home with a good luck, hope it works out for you. So they did say you have to have this process. You have to send them home where it's applicable. That could be again to a long-term care unit, or it could be back home, depending on what their status is. And the other thing they noticed is some information that gets in along with patients. What was their course of treatment? What were their goals, of course? And this has to go to where the person who's going to be taking care of them, they need to get this. That could be an oxygen supplier, that could be again care, somebody who's responsible for their follow-up and their ancillary care. Because they noted that there was a lot of missing information. And with that, we notice that, hey, we've got an increase in our readmission and bad outcomes. Whereas when we sent the correct information and sufficient information, it was lower. Patients and the caregivers were able to take care of them. And the other thing is, if that information doesn't go along, let's say the patient's transferred over to a long-term care, they need wound care. Nobody told them that. Well, maybe they're not equipped to take care of them. They're not ready for them. They don't have that staff to take care of that wound. You can develop your own policy and procedures to meet these. CMS won't spell that out for you. They just want this information covered. Because there were six major areas of concern. Medications was a big one, where patients were being double-ordered medications in the same classification. Or they weren't ordered anything and they were supposed to be on it. Another one was skin conditions, that the actual skin condition wasn't communicated like, oh, it's got some redness there, maybe a small decubitus forming on the coccyx. And of course, those who do have the behavioral health issues and those needs, whether serious mental issues or the substance use disorders. These were the six areas of concern that when CMS was doing their surveys noted a lot of the information was missing. All right. Let's go ahead and really quickly talk about the discrimination component and interpreters. Some of the provisions in 1557, just to back up, that's the Affordable Care Act, they overlap with the changes. Now, CMS said, well, what if we just throw that into our conditions of participation? Well, in the end, they decided not to do that. Because first off, it would mean you have to make sure you're in two different areas and that they're corresponding and any changes with one got updated in the other one. And they said, well, that's just, we're not going to do it. So now, you do want to make sure that you're following 1557. The surveyor can send it over to the Office of Civil Rights if they find a violation. Overall, there's two signs that are required they must post. These have to be in places where patients first come in, admitting, emergency department, maybe it's OB. When you have those direct admits, you have to have someone to handle complaints. That has to be in their job description and a policy to make sure staff know about this nondiscrimination policy, what they need to know, and that they're competent to do their jobs. So as far as the actual provision, they're talking about the law that prohibits discrimination based upon what's called the protected classes, race, color, national origin, age, disability. And that's for those who participate in health programs and activities, i.e. Medicare and Medicaid. And really adds more civil rights protections on these. So I'm gonna do a little quick brief history. I'll make it brief. Before, there was a judge that had an order that you couldn't force a hospital or a provider to do something that goes against their religious beliefs. OCR said, hey, we agree with that. We're fine with that. We're not gonna penalize them because you happen to get a patient in who wants a surgery that, no, my religious belief doesn't allow me to do it. That goes against my belief. So OCR is fine with that. At that time, they returned to that position under the term sex because that's one of the protected classes. And they do recognize it does not refer to gender identity. And also they recognize, yes, we know that abortions, that does conflict with my right under 1557 as a provider. So great. They went back and redid 1557 to follow this ruling. Well, May of 21, Health and Human Services said, we are going to enforce that prohibition on discrimination based upon sex to include, this is different, include orientation and gender identity. Well, a federal court in Texas said, nope, we don't agree with that. And they set it aside, said, oh, HHS, you overstepped the definition. Now, OCR is currently revising the regulation. They are adding a prohibition to the regulation on discrimination based upon sexual orientation and gender identity. These are the appendices that are affected by this particular rule. They're hoping, and I'm telling you right now, it wasn't done. The final action was due in January of this year. It is not out yet, but just keep in mind that OCR and Health and Human Services will include gender identity and orientation in their definition. So these changes are coming. I'm still got my fingers crossed. It's gonna show up pretty soon. Another, some of the changes talked about language assistance. We're very familiar with that. We've been providing interpreters or some interpretive services for many years. This is not new. What they did do was they qualified or clarified that your interpreters must be qualified. Somewhere along the line, I got confused what they have to be certified. That's not correct. Just qualified. In other words, as an interpreter, they can speak the language sufficiently and correctly so that the medical terms translate appropriately and they can relate it back to you from an individual. And then you have your translators. That's the written form. So essentially it's the same thing. You have to put up a sign. This is one of them. So that when patients come in, that they know they have access to interpreter services at no charge. There are 15 languages for the majority. Four states and the District of Columbia have 17. And in part of this, you also have someone in charge to handle these grievances. So I've listed here how you find that list of your top 15 languages, or you happen to be one of those lucky states that have 17. There is the link. Go to where it says Appendix A. By the way, you're not required to use that list. You can use your own list. Maybe your state has another listing of the most frequently spoken languages in your state. You can use that list. You just have to be able to produce it and CMS asks for it. So this is the one that they put together. And for those of you who might have 17, that's how it would come out. They would list that on one line as the last one. Again, Colorado where I am, that's one of them that happens to have the 17 languages. Okay, let's go ahead and start with the conditions of participation. Mandatory compliance. If you accept Medicare, Medicaid funds, you have to meet these requirements for all patients. If you have Dean status, it's great. You can get reimbursed without having to go through agency, but just know that they are probably starting to tag along. There have been some concerns with some of the other agencies that they're not following to the letter some of the CMS requirements. So don't be surprised if they come along too. Nursing services. Overall, you have to have an organized service to give 24-hour services, seven days a week. You have to have at least one RN who either provides or supervises that care 24 hours. That means you have to have an RN on duty at all times. It has to be integrated into your QAPI, hospital-wide. The surveyor is going to want to talk to your chief nursing officer. Could be director of nursing, however you want to call them. They want a copy of your organizational chart because what they're looking for is a chain of command. They'll look at job descriptions, including your chief nursing officer, and they'll at least take one patient from every unit and they'll watch care being provided. They want to make sure you have adequate staffing. They're going to look at your medical records. They're going to look at care plans. Are they current? Does it reflect the care that's being ordered and the care that's being provided? As far as your director, well, again, they're looking for a well-organized administrative authority and delineations of these responsibilities. So your CNO, DNO, I'm just going to refer it to CNO, has to be currently licensed RN. They are responsible for that nursing department. They are responsible to decide how many and what types of staff do you need. Now, that doesn't mean just nurses. That can be supervisors, directors, unit clerks, orderlies, aides, whatever you put on. They have to determine how many do we need in order to provide safe and quality care to our patients. There must be one service hospital-wide and that includes making sure there's the quality of care of nursing that is being provided. So the CNO, again, they will verify the CNO approves policy and procedures. I want to stress something here and it came up as a question a while ago. Does a CNO have to develop all of these policy and procedures by themselves? And the answer is no. They can delegate that, but they have to approve them. So in short, the CNO must know and approve what those policy and procedures are. They have to develop the nursing service staffing policy and procedures. How many are you going to need? When are you going to need them? What quality? What levels? They'll look at the chart, again, lines of authority, and they'll look at the job description. Does it spell out the duties and responsibilities within that nursing service? You have to have enough, of course, staff take care of patients and qualified supervisors for those to make sure that, okay, you've got one RN on a unit, that's great, but they have to be able to provide care, backup care if needed. So if an LPN is taking care of that patient that you've got an RN on that unit to run in and help if that's the case. That means every department has to have an RN. If they're working on two units at the same time, that's not available, that won't meet the requirements because they want an RN at the bedside if needed. So you may need to look at your staffing to account for absenteeism. Maybe there's a pool of nurses, maybe you have to go to an agency in order to be able to provide those standards. Immediate availability, that's when needed. So again, if they're working on more than one unit, one floor, it's not meeting the requirement. It doesn't matter if it's inpatient or outpatient because if you're an outpatient area, you still have to meet the same level of care, same standard as if they're inpatient. The surveyor will look at your schedules. They wanna make sure that you've got enough staff for the acuity of your patient. Those who are on a step-down intensive care unit are gonna have a higher acuity than say those on a med-surg floor. Not always, but usually they do. And then they wanna look at the training of your personnel. What's their experience? Do you have a brand new grad who's in the intensive care unit, who's a charge nurse? You might wanna revisit that delegation as opposed to a nurse who has 20, 30 years of experience and training. Those who've gone on and say gotten certification and PALS now, ACLS, whatever it happens to be. And then of course, how big are you? What's the layout of your actual hospital? Are nurses running from one end of the floor to the other just to take care of patients? That may not be the safest, effective way as opposed to keeping the more critical ones close to the desk and having one or two take care of them. But again, you have to determine acuity and your staffing. They'll look at records. They, again, they wanna make sure care is provided as ordered. On staffing, I'm just gonna bring up these three studies that came out. And most of the nurses who, if you're listening to this, you know this. They know if you have enough staff, you're gonna have better outcomes. And this was really, this one came out in March of 07. And it said, the more staff you have, the better outcomes you're going to get with your patients. Institute of Medicine, they also found staffing was linked to safety. You have enough staffing levels, great. But they also went so far as say, limit how many hours you're working your nurses to prevent fatigue. They suggest no mandatory overtime. They can do overtime, but don't make it mandatory. Let that person decide. And never work more than 12 hours in a day or 60 in one week. They noticed three times the error rate. That's pretty significant when you think of it. I remember, and some of you may also, when we had eight hours, we would do a double shift because short staff, there was other qualified individuals. But I'll tell you by the end of those 16 hours, you're pretty wiped. And you almost got to the point of, oh, I don't really care. Let's just get this shift over with. And that's why now they're finding fatigue impacts quality of care. And they've noticed that other areas, error rate and medication goes up. Pressure ulcers, because we're just too tired to go turn them. Keep them going. Falls increase, UTIs, readmission rate overall goes back up. AHRQ, they actually put out a three volume handbook for nurses and it talks about staffing and care quality of care. And again, patient quality, that's affected by short staffing, which brings us to question number two. Lindsey. Okay, let's get that one up here on the screen. I'm actually gonna read this first part there for you and then I'll put the question up there for you. This says hospital B is a 320 bed hospital with service provided on three floors and an average daily census of 275. It experienced a major nursing turnover in the past year with a significant shortage of RNs. Hospital B runs with six RNs per day. Will this be a possible issue with CMS? And then let's get the question up so you can respond there. Or not sure. And then Laura, we do have just a couple of questions that have come in. This first one asks if you can clarify if a hospital can be cited for discrimination if a provider chooses to not perform gender affirmation surgery. Yes, because what they have to look at is providers, hospitals, you have the same rights. They're not going to impose upon a provider if it is against their religious beliefs to do something. That's not right. They recognize that. And they're not supposed to cite them because no, you can't. That's the provider's own right to say, no, I am not going to do this. It goes against what I believe in. So then we have to provide another way to take care of that patient. And I always come up with one where perhaps you have a patient who comes into the emergency room and is requesting termination of a pregnancy. And the providers there say, can't do it. Then we have to make arrangements to get that patient that care that they need. And in a timely manner, just think MTALA. And if the patient came in, major auto accident would still transfer them out if we can't or couldn't take care of them. So again, they're not supposed to cite you on that. That is a violation of OCR. Perfect, okay. And this next question says, we are a small 25 bed critical access hospital and we staff one LPN at night. And she covers all patients to include the emergency department of which is low volume. Appendix W states that an RN can supervise offsite and does not require in-house supervision. Yeah, correct. Yeah, and we're gonna get to the critical access staffing issues. But yeah, criticals have more of a challenge of trying to have RNs on staff. Check your state law though because the state law may have a little bit stiffer requirements. And so you might not be cited under CMS. That doesn't mean they wouldn't maybe refer something to your state. Yeah, and there's another comment here in the chat asking what does state laws prohibit gender affirmation surgery? Seeing these laws constantly going into effect state by state. And again, I think that comment applies there to make sure that you're checking your state laws. Right, correct. And this last question I see, is a refusal for blood products required or recommended? Could you repeat that question? I'm not clear on. Yeah, Jennifer, I see this question coming from you and we may need a little bit more clarification from you. It says, is a refusal for blood products required or recommended? But I'm not sure. Yeah, I'm not sure what that. It's a cool question, West Height there. But I just need some further clarification. Okay, I'm gonna go ahead and end this polling question and share those results there. Great, okay, so yeah. Yes, they will be cited. I mean, that's a good size hospital, 275 beds. Okay, this is for acute hospitals. You have to have a 24 hour nursing service supervised by an RN. And again, rural hospitals, if you have that waiver because you have a temporary shortage, fine. You can get away with that. These are rural hospitals, 50 beds or fewer. You can get that temporary waiver but the regional office provides that. Otherwise the surveyor has to verify that there is at least one RN on each unit, 24 hours with that particular situation. They didn't have enough RNs available 24 seven. You have to have a way to make sure your nurses are licensed and that's current and it's valid because we wanna make sure we meet those standards. Continuing ed, certification, training. Some states no longer require nurses to have continuing ed units. Some still require it. Your hospital can require it. So my state doesn't, but the hospitals here, they want the nurses to stay current. And the majority, even our critical access hospitals, they're saying, no, we want them to get CEUs. We want them to stay up and stay current. Surveyor will look at the HR records. They wanna make sure they're licensed and they're current. The most of your board of nursings will have that verification available to you online. It is considered primary source verification, printed out, put it into their folder. If you have advanced practice nurses, don't forget to look at the office of inspector general's list of excluded individuals. These are those folks who cannot participate because they violated OIG rules. And that's usually fraud and abuse, those type of issues. So you might wanna check those. Your HR person probably already is doing this. Overall, you have to have an RN for every patient. Now that doesn't mean they have to actually do all of the hands-on care because they delegate it. They do that admission assessment and make sure they're following acceptable standards of care for everybody and the hospital policy and procedure. And this is somewhat of a problematic standard. Evaluation, making sure you're looking at what are the patient's needs? What is their health status? How are they progressing? And then when do they need to intervene? Let's say you've got a patient LPNs taking care of, good LPN, and the RN trusts them, are they still required to report to the RN when there's an issue going on with that patient that perhaps the nurse, the RN can intervene or maybe we need to get the provider involved. Another major area was our nursing care plans. That you have to make sure that your staff develops and keeps it up to date on every patient. And they mean every patient, and these are inpatients. I'm gonna kind of stress that. First off, outpatient, ER, probably not. It has to reflect what does the patient want? Are we meeting their needs? What are their treatment goals? Where do they wanna end up? How do they wanna do this? So you've got a patient, multiple trauma, seven fractures. What are we gonna do with this one? Well, this person was up moving around, very athletic prior to this accident. What do they wanna do? I'm gonna get out of here and go back to doing what I was doing. Okay, how are we going to do that? Maybe they go to rehab for a week, really aggressive rehab. And then maybe they wanna go to one where their daughter lives or another family member lives or one they've heard about that is so phenomenal. But the idea is we wanna get them back to that pre-admission state as possible. So as far as the care plan, it starts on admission and we include what's going on with this patient. What is their physiological? What's their psychosocial? What is their social status? When I mean social status, do they live alone? Where are they in that post-care treatment? Because that's what your assessment has to take into consideration. We're probably gonna have to reevaluate that patient's treatment goals, their needs based upon that assessment. Did it change? If you have interdisciplinary care plans, great. We still have to have a nursing care plan. It's not eliminated. It can be part of it. You can coordinate it with it, but it still has to have an individual nursing care plan. That has to be a part of the record and be initiated soon after admission. Usually the surveyor looks at anywhere from 10 to 12 care plans. They may go as low as six, depending what your census is, but that's what they wanna look at. Did we do what we were supposed to? Another tag number is where we have an RIN who assigns care. And of course that's based upon what is the patient's needs and what kind of staff do you have? Do you have really good staffing? I remember we had, in our unit, we had a 12 bed coronary care unit. And the charge nurse, she had a lot of confidence in us and we worked well as a team. At some point in time, we had 12 patients and there were three RINs, but she had a lot of confidence. Was it probably the safest way to do it? No, probably not, but that's what we had. And then eventually we were able to start getting more staff. So we had to look at the competence of the staff. What is their training? And if possible, again, more RINs, the better the outcomes. You have to make sure the RIN is making these care assignments. The CNO makes sure staff has proper education, experience, they're competent, and they're qualified to take care of these. They, again, can delegate it, but the CNO is ultimately responsible and must make sure this is happening. The surveyor will look at your assignments and they'll compare them to who's assigned to this individual. They'll talk to your charge nurse or day supervisor, whoever that happens to be. What did they take into consideration when making these assignments? How sick are your patients? Do they have special needs? How is this RIN qualified to take care of this patient? Do they have other experience that comes into play? And you may have nurses' aides that are just great, that can really be a huge benefit, that the nurse doesn't have to be in there, that the CNA can do this according to their qualifications and what the state says they can do. So don't have to have an RIN for each and every patient. Agency nurses, they're just like your staff. CMS will call them non-employed nurses. Nonetheless, their CNO still has to make sure, just like any other staff member, there's enough supervision to see how they're performing. And let's say, look at them once a year at least. Now, this could be one time, if that's the only time you use them, but just make sure that someone's watching and supervising the care they provide. Now, this could also be not just agency nurses, but your volunteers, if they're doing patient care. We wanna make sure agency nurses, volunteers, they know what your policy and procedures are. So that's where your orientation is so crucial. And by the way, they really want you to make sure you hone in on your specific unit, emergency procedures, and safety policy and procedures. For example, are they familiar with what to do if the fire alarm goes off? Are they familiar with what to do if, say, you get an active shooter alert that comes through? Do they know how to respond? Briefly on outpatient departments, you have to have a policy and procedure that lists them and which ones have to have an RN present. Now, that decision is based upon what you're doing, level of acuity, and what's the standard of practice. And I always refer to, in radiology, let's say you're doing some of the mammograms where the patient lays face down and they're face down for a long period of time. And they can get a little claustrophobic in there. I've had some services that say, can we give them sedation? Yeah, you can, but what are you gonna do to take care of the patient while they're getting the sedation? Are you gonna monitor them? Who's gonna monitor them? You need someone, i.e. an RN, who's qualified to do that. You have to have an alternative staffing plan and the CNO must approve it. Again, outpatient review it every three years. What do you need and what are their qualifications? So I just put some examples. You got a chemotherapy or a hydration service that you provide. Radiology department, they helped with those who are getting moderate sedation, but you may not need them. Outpatient MRI, eh, probably not. You won't need an RN there. Okay, here's the big part of nursing and that's medication administration. Drugs, that's what they call them. Have to be prepared and administered according to state and federal laws. Rule number one, you have to have an order and it has to be for all medications, whether it's written by hand or it's a standing order and it has to be in the record. They have to be administered either by or under the supervision of nursing or other personnel, because that could be a PA, if that's approved by your medical staff policy and procedures. Orders of other practitioners. These are your advanced practice providers, PAs, nurse practitioners. We have to make sure state law says they can do it and their scope of practice says they can do this. But we also have to have hospital policy and procedures, your medical staff, bylaws, rules, and regulations. They have to say, yeah, PAs can order that if that's what you want. Interpretive guidelines talk about medication errors and they talk about the studies on medication errors. We all know the eye and how many were affected by it. 800 and almost 40,000 patients were either treated for a medication-related adverse event. And this is still in spite of computerized ordering, bar scanning, we're still unfortunately having medication errors. Medications have to be prepared and administered using standards of practice and federal and state laws. And when I think federalized, I always think of your narcotics, your scheduled drugs, but also if you're doing research. There are specific organizations that CMS actually list that talk about the guidelines. I'm not gonna say them all, they're right there, but these are just on the CMS even references. This is still in 405. Again, 405 is a massive tag number. For standing outpatient orders, you can do that. And this includes outpatient services and orders coming in from practitioner privileged by your medical staff. That's up to your hospital if they're going to allow this to occur. I always think of x-ray, laboratory. There are two exceptions to that, flu and pneumovax. There's just a protocol that you have to have in place. Nurses assess them for any contraindications and they can administer it. They don't have to go get the physician, get it all taken care of. I always think of that when I go to my King Soopers, my grocery stores and the pharmacies to get my flu and pneumovax. They're operating on protocols in order to do that. The practitioner order, there are certain requirements. Of course, we have to have who and maybe age and weight. This is really to help with those calculation. Policies for children and newborns. Don't forget your elderly patients. They may have low body weight or they've got other issues such as renal or liver failure that can affect the metabolism of that medication. But do a unified approach with your orders. So one doctor's doing it, then the next provider's doing it. Another one is the date and time of order. About five years ago, CMS really honed in on checking date and times, making sure those were documented with the order. I just wanted to include this. This happens to be the dosing chart for two medications for children, or it says use kilograms for kids. Overall, the other order requirements provides the patient information. What are you giving? How much? When? What route? Maybe the strength or concentration or quantity. How long is this going to run? And specific instructions. And then finally, who's ordering it? The name of the prescriber. The medical staff has to approve policy and procedures on administration. And it should, of course, be part of QAPI. Has to be done in consultation with nurses and pharmacists. And I like that because nurses administer and pharmacists really are up to date on the medication issues. And again, they've reiterated they're administered under the supervision of nursing or other personnel. Now, there are many specifics that CMS has that need to include or be included in the approved policy and procedures. Of course, consistent with any scope of practice or state law. So here's some of the requirements for those policy and procedures. Who can order them? Who can prepare them? Who can administer them? I've got the page number in Appendix A listed there for you. What type of medications can they administer and prepare? For example, my nursing board, LPNs can administer certain IV medications, but they have to have documented training and certification to do that. That's why your state law is so important here. What are the education and the training requirements? CMS does have certain recommendations. Of course, we always want it during orientation and continuing ed. That may be, how are you gonna handle these and prepare them? What are the side effects, drug incompatibilities, dose limits on certain medication? How about that equipment they're using? Any special devices that they have to be able to set up and troubleshoot if it's not working? What are the components of that training? This is what your policy and procedures have to include. Again, orientation, continuing ed. We wanna make sure they have competence to do that. And then documentation of that training and competency. We all know the five rights. These are the basic, overall been around since almost Florence Nightingale, five practices and five rights that we've had to know. Right patient. So how are you gonna do that? How are you going to identify him? Full name. Are you gonna use our D number? Barcode scanning, date of birth, whatever. That's gotta be in your policy. Are you gonna identify this patient? Right medication. This is what was ordered. This is what I'm giving. And there's no allergy. The right dose. It matches what was prescribed. The right route. And then the right time. Because we wanna make sure that we're adhering to the frequency and time of administration. Now these five rights also focus on the process of administration. So here's the medication process. There are again, five stages. And it starts with ordering. And then someone has to take down and write it out or verify it. And that's usually your pharmacist. Then they have to dispense it and get it up to the floor. Then the nurses have to administer it. And then there's monitoring of the patient. How did they react? CMS talks about some recent literature had talked about nine rights. And here, just a blue box. It can't be cited if you don't do this, by the way. It's up to you. It's up to your hospital, your medical staff. If they wanna do this. This talks about the nine rights. And others say eight or 10. But the minimum is five rights. Some do seven. They also have to have that culture of safety. And we've heard a lot of talking about culture of safety and the work environment. Well, really what they're trying to say we're working as a team. And if I've got a question as a nurse that I'm gonna feel comfortable going up to that prescriber and say, I have a question on this and I'm not gonna fear getting my head bit off. They have to be able to do that. There has to be that collegial collaboration. They have to be able to bring questions because that could save a patient's life when they do that. And get them resolved promptly. Don't just say you figure it out. That's not the proper response. They also talk in here safe injection practices. So we reduce those healthcare associated infections. And this isn't just giving them a shot. It's also the actual preparation of that medication to make sure it's sterile. In these situations, you will be assessed under the infection control section because compounded preparations, they can cause infections if we're not following the steps correctly. You may end up doing that. Your nurses may end up preparing them for immediate use. ISMP, they put out their guidelines on IV push medications. They put them into those categories that increase the risk in adults. And it talks about current practices, guidelines. 90% of your patients are going to have some form of infusion therapy. So very quickly, one, provide these medications in a ready to administer form. There's no calculation, no combination. They give it. Commercially available or pharmacy prepared syringes of solutions. And in particular, those that flush the IV access. If it only comes in a single dose file, buy it that way. You decrease your chances of contamination. Aseptic technique when preparing. That means hand hygiene before and after. Cleaning off the diaphragm. Even if you just pop off the cap, clean off that diaphragm. Only dilute medications when the manufacturer has recommended it or you've got some evidence-based practices and policies that support dilution of the medication. If it does require dilution, it needs to be done in a clean, separate, uncluttered area. In short, your staff isn't having their lunch while they're preparing this. There's a separate clean area. You don't take medications from one syringe and put it into another for administration. And of course, don't use your flushes in order to dilute medication. That's for flushing, that's not for dilution. Putting more than one medication in a syringe, seldom necessary. Also, we never want to use those common bags to flush lines. Label your syringes unless you immediately give it. Short, don't leave your hands. You draw it up and you administer it. Give IV push medications the rate that the manufacturer has recommended. Sometimes we give them too fast. Now, CDC even has recommendations that talk about injection safety. And this talks about isolation precautions and transmission. It summarizes their 10 recommendations. CMS does expect us to follow those. I have them in the appendix for you. So just to save time, that resource is available for you in the appendix. And this is question number three, Lindsey. Okay, I'm gonna read this top part and then I will post the question up there for y'all to choose your response. So this says, hospital D has four stock of vaccines and saline or sterile water for dilution as needed. All vials are multi-dose with an expiration date clearly printed. During a state survey, several vials were noted to not have a beyond use date printed or affixed to the label. Nursing reported this was a duty of pharmacy. Pharmacy said it was nursing's responsibility. Will hospital D be cited? And then let's get this up here for you. Okay, your options, yes, no, or do not know. Excuse me. We do have just a couple of questions, Laura. Our attendees are posting those responses here. Okay, let me scroll back up. This first says, is the waiver applicable for 50 licensed beds or fewer or licensed for more than 50 but an average daily census of less than 50? It's what you're licensed for, not your census. That's what they're looking at. That's a good question. Good question. Absolutely. Okay, and then this says, we have attempted to make employee files electronic. Our state board has online license verification. Is documentation of a primary source verification acceptable? Yes, as long as you go to your board of nursing, again, that's primary source verification. Are they licensed? Because in order to get that license, they have to show everything. We had an incident where the board of nursing got to hand it to a man. They were on their toes. We had a nurse who was trying to pass herself off as an RN when in fact she hadn't done anything. And the board of nursing stuck to their guns and said, you haven't proved anything. We need to have verification because they went back and verified no schooling, no training, nothing. So yeah, your state board of nursing is considered your primary source. Same with the board of medicine. Perfect. Not that you don't wanna go back and do more. Oh my God. When you see a nurse bouncing or even a provider bouncing from job to job to job to job, that's a red flag. Something's going on. Great. All right, how are we doing here? Yes, they, oh my good, yes, indeed. All right, beyond-use date. This is when the drug goes bad or it's beyond-use date. Now the manufacturer sets the expiration date. That's based upon what they had to go through to get this thing FDA approved. All of that, testing, stability, everything. But the beyond-use date takes into account much more because now we've got it reconstituted. It's been open. And after that fact, all bets are off. That is based on information that comes from the manufacturer. For example, they may say this thing will expire in December of 2026. But once reconstituted, it is only effective for 48 hours. The beyond-use date is that 48 hours. So that's why you have to have your policy and procedures spell out clearly how you determine that beyond-use date. And especially if the manufacturer doesn't provide it. So you may want to work with pharmacy. In this particular situation, the pharmacy, they reconstituted all of the medications and they were responsible for putting that beyond-use date on there in that particular situation. Administration itself. Before, you had to give all medications within 30 minutes. Otherwise, you were outside your scope and you had to write an incident report and it was just a headache because sometimes you get busy and it can't get done. Just physically can't get done. Now, in working with ISMP, CMS came up with three blocks of time. So make sure, looking at your policy, that you're adhering to it. So first off, you have to have a policy on timing them. What is the nature? What's the clinical application with that medication? You want to include in that policy those who are not eligible for dosing times. Those who are eligible. What happens if it's outside? Administration occurs outside that window of time. And then review of those policies. Maybe we can expand something or we need to shorten the timing. There are three of them. One hour before, after. Two hours before, after. And again, these are medications that are eligible, but for those who are not eligible for scheduling. Stat drugs. Just think of those classifications. I'm not going to set that up on a timeframe. Loading dose. That depends on what's going on with the patient. Pre-surgery. Maybe there's a serum drug level that you have to get. All PRNs, those are usually not on schedule. Those are when the patient needs it. And investigational drugs. Those are those are not eligible to have a scheduled administration. And then you have everything else. Those that are prescribed on a repeated cycle. That could be daily up to four times a day. The idea here is we're trying to get that blood level. Now that may mean 9 a.m., 8 a.m., 8 p.m., whatever happens to be. But have in your policy what those standardized times are. Because the pharmacy has to know when do I need to get this drug up there? Nurses have to know, do I assess the patient? Do I need to look for lab work in order to make sure, yeah, it's okay to give it? So with these timeframes, the one hour before, after, you get a total of two hours in your timeframe. So if it's ordered at 9 a.m. and you have the one hour before, after, you can give it at eight or you can give it to 10. Let's say you have the two hours before. It's only once a day. Maybe it's LASIKs once a day. In that case, then you have two hours before or two hours after, four hours. If I'm ordered at eight, the patient's awake, they want to get moving, I can give it at six or I can give it up to 10 a.m. I have those four hours in there. So your policies have to address, first off, when it's the first dose of medication. These are ones where the patient has not been on them at home. When can the nurses use judgment on fudging on when the next dose is going to occur? And I don't want to say fudging because that's a bad connotation, but when can they use that judgment to say, okay, I can give it at this time and then give it here and I'm good. What if your patient misses it? They're nauseated, they're off the unit. Maybe you do have some meds that can be given outside of those dosing times, regardless of what the normal timing is. And then do you have certain units that don't even follow those dosing times? I want to start with time critical because that's those where you have to give it in that timeframe of 30 minutes or less because anything more, you're not going to achieve the effect of that medication. So what medications, that's what your policy has to address. What medications are administered within that timeframe? These are medications that are usually critical. That could be your anti-epileptics, insulin, your anticoagulants, because we really have to base those and keep them on that scheduled timeframe. Non-IV pain meds, again, those that are also maybe ordered more frequently than every four hours. Then again, everything else that's not so time critical. You got a little bit longer, a little shorter, it's not really going to impact the efficacy of that medication. You can give two hours or one hour. So either four hours before timeframe or two hours. But again, you have to make the determination, medical staff and working with pharmacy in particular, what are these medications and what do we need to give them? That's your policy has to include again, what happens if you miss it or it's late? When can the nurses use their own judgment on rescheduling that missed dose? Report these to the attending. The attending may say, ah, skip that dose, give them the next timed one, which is say in three hours as opposed to four hours. So let the attending know that. Periodically evaluate those policies. By the way, look at how your staff is adhering to that. There may be something going on in the unit that you're unaware of. And that's why you want to include nursing when you're working with these timing policies. We wanna make sure it's safe and effective administration. We always include this in QAPI, especially errors. Why is this happening? What's going on that we're having these timing errors with the administration of medication? And medical staff, we may need to revise those policies if that's the case. Otherwise, we monitor our patients. Are we hitting that therapeutic effect? Are we giving enough time for early identification of bad side effects and how we're going to quickly get in there and take corrective actions? If you're giving medications that are very renal, toxic, doing those peaks and troughs, watching how is their BUN doing? What's their creatinine doing? Maybe there's other information that you have to look at. Physical signs, are we getting confused, agitated, itching to show some kind of a reaction? We always wanna look at our patient. What are their risk factors? And what's inherent in that medication when we're looking at timing and frequency of monitoring? We wanna make sure that when we're doing handoff, we're doing report, whatever it happens to be, we're communicating these issues going on with that medication administration. Always report those adverse events to the practitioner, whether it's anaphylaxis, or we've got some respiratory depression, or some other reaction to those opioids. They have really focused on opioids. But overall, what they're looking at is, of course, what kind of patient do you have? I'm not gonna list or go through all of these. We know our patients, are they opioid naive? Or are they overweight? Do we have a big patient? Do we have a smaller patient? Sleep apnea, that's another big one. And age, maybe they're older, maybe they've been on these medications forever and they have a high tolerance to them. Or again, opioid naive. Now, separate from opioids, including them, but separate are other high alert medications. Because you may need to do other assessment. Usually you do your regular assessment of the patient. What's their pulse ox? How awake are they? Especially patients who are post-op and those who are getting your PCAs. But you also have to make sure that your monitoring includes, how's the patient responding to this medication? Have you ever taken morphine in the past? How'd you react to it? What about Demerol? We wanna make sure we're talking to our patients, our families, those who are visiting them. Notify me if you see a change in this patient's behavior. The patient won't know, they won't be able to relate it usually. But if the family is there and they see their aunt getting, trying to get out of bed, talking very strangely, get the nurses. They know to do that. And your policies, again, how often and what is the manner of monitoring? Looking at all of those risk factors. What factor you use, what resource, that's up to you. CMS won't tell you, you must use the Richmond scale. You decide which one works best. Just make sure it consistently applied. And then documentation, they also address it in the medical records section. And they talk about specific content. And for example, nurses notes, they talk and you must document reports of medication and the treatment after administration. Note in the guidelines, advanced documentation is inappropriate and can result in errors. Surveyor, they wanna look at your policy and procedures. First off, have they been approved by everybody? That includes ordering. They'll make sure that they cover who is authorized to administer. They will verify that nurses are acting within their scope of practice in the administration of those medication. And if it's other than nursing, are they acting within their scope? Hospital policy, bylaws, federal rules and regulations, you know, the usual. They wanna make sure you've identified those Medicaid scheduled dosing times. Those who aren't eligible, those who are, are they time critical? Are they not time critical? They wanna make sure you have those established time requirements and they are not exceeding. That's why they're going to look at records. So if you've got a medication, it's ordered to be administered at 8 a.m. It's one of those time critical ones. And they see documentation, it was administered at 9.30, they need to know why. That's what they're looking for. And they'll verify what are the requirements for those time critical. Is it simply unit specific or is across the hospital? You can have different timeframes depending on the unit. Again, the other things they'll look at the sample of records, the orders. Did we do the five rights? If the order is still in effect, the medication was administered. They wanna look at standing orders. Are staff complying with those? Then they're gonna stand around and watch drugs being prepared and administered. Did they confirm the identity of the patient? Did they do the minimum five rights? Did they follow the policies? That's why they wanna see your policies. Were patients assessed for, how'd you do with that medication? Getting any relief from that pain medicine or first time antibiotic use? Did they go back in so many minutes and check on the patient? Those who are at risk, did we monitor them for those adverse events? And the staff know what to do if there is an adverse event. What do you do if that patient's getting that IV antibiotic and all of a sudden they say, I'm having trouble breathing. What are they going to do? Now talk to your nurses. Do they understand what this policy is on timing? Can they identify if it's time critical or non-time critical? Can they describe what are the requirements of timing? What do they do if the timing is off? Can they use their own judgment? And then standing orders. Again, are they compliant with the requirements? Like I said, 405 was a very long tag number, very involved. Then we have our physician's order. We have those where you have to have an order. You can use pre-printed electronic order sets, protocols. Whatever it is, it has to meet the requirements under the medical records section with the exception of your flu and pneumovax. But you still have to have a protocol that allows it. Short, I come into ER and I'm there for sprained ankle and they're looking and says, hey, you haven't had your flu vaccine. You want to get it now? They can follow the protocols in order to administer that. But as far as the orders, they have to be documented and signed by a practitioner who can do that. Of course, that's by your medical staff rules, regulations, your policy and procedures at the hospital. What does the state law say? Say a non-physician can order. And this, by the way, includes not just PAs and nurse practitioners, but also surgeons, oral surgeons, podiatrists. And if doctors can write orders, of course, then what other staff can write orders? Standing orders. Now, I'm just going to say standing orders protocols, they kind of lumped them together with this. So nurses, standing orders are those that the nurses can carry out. And of course, the physician has to sign off on them, but those are there. They know what to do. They don't have to get on the phone and say, their blood pressure's dropping. What would you like me to do? They can follow those standing orders. And that's why, even though they've got multiple names, CMS does say these are standing orders. So what you have to do is you have to have a way to address those well-defined scenarios involving medication administration. Now, tag 457, again, that's in the medical records section. It really spells out what those requirements are. Overall, the practitioner still has to sign off, date, and time it when they want those standing orders. So here's just examples, a code team. They have, what they do in ACLS, you know, when they're following those algorithms, that's a standing order. Chest pain protocols, I come into ER, there's protocols you can follow. Put oxygen on me, get these labs done, do an EKG. Those are standing orders. Verbal orders, if you're going to permit them, use them infrequently because too many errors come along with them. And of course, it's never for the convenience of our providers. We understand they're busy, but if they're standing there, hand them the keyboard or the chart, whichever it happens to be. These are usually used when the surgeon, the physician, they can't get in there to physically write their orders. There are four items in your policies for verbal orders. One, what are the limits on use? They specifically say no chemo. Two, what are the elements for a complete verbal order? What do you require that verbal order to include? What are the protocols? So you've got good communication. In other words, maybe it's a readback. And how are you going to identify who's writing that or giving that verbal order? Your policies also have to stress who can accept them within your hospital. These are those who maybe your state law spells out who can accept verbal orders or federal law. For example, you may allow pharmacists to accept drug orders or you don't accept vancomycin IV from a medical assistant in the office. It has to come from that physician, the office nurse, someone who's authorized to give that verbal order, communicate that verbal order. And of course, documented in the chart. Now I want to point out two changes that were in the medical record checker. They're not in the nursing, but I want to point them out here. Verbal orders authenticated based upon state law. Some of them say 24 hours, you got to sign off on them or somebody who's responsible for the care. Say your one physician orders it verbal and they're headed out of town. Covering physician comes in the next morning and signs off on it. If you don't have a state law, make sure your policies address soon as possible. A week later is not as soon as possible. Just make sure your policies stress. What is that timeframe that somebody, the covering physician, whoever it is, can sign off. Then there's other practitioners. Again, who can do that? PAs, nurse practitioners, dentists, who is allowed to write those orders. They have to still be documented and signed off. And this is a new one, by the way, with their hospital improvement, they did make that change. Then blood transfusions and IV administration. Following state laws, before CMS had this laundry list of training that was required. Well, they said, yeah, that doesn't make any sense because this usually happens in training anyway. And you have to be competent to perform your task. And so that's why they took out that huge list. They still put the onus on the hospital to make sure the person who's administering those IV meds are qualified. They're competent to do that. They're following policy and procedures. They're following their state scope of practice because you still have to follow that. And in some states, LPNs can't hang book. They can't push certain IV meds. If they are allowed, you still have to have documented competency for them to do that. Approve policies from your medical staff. And of course you have to follow them. Policies for these have to be based on state laws. What is the vascular route? What are you gonna allow the nurses to administer? Are you gonna allow blood to go through a central line, an implanted port? What medications, IV medications, can you do this, can be administered via those ports? Is it all peripheral or can you do that central? Then just follow basic safety practices for medication. Trace the line, make sure your pumps, everything is properly programmed. Those of you who've probably seen these type of situations, that's nothing, but you're very familiar, trace the line and make sure you're going in the right area. Then we have patient monitoring. The interpretive guidelines talk about monitoring the patient for the effects because IV acts a lot quicker. What are the assessments of those risk factors that could influence how often we're monitoring them? Policies are expected to address watching your fluid and electrolyte balance. If we're filling them up with, say, normal saline, we've given them Lasix, okay, great. What's their potassium doing? Especially those who are on high alert meds. Opioids, wanna keep an eye on over sedation. Here's just the risk factors that CMS points out. These look very familiar, don't they? They talked about just general medication risk factors for the patient, where they're opioid naive, history of sleep apnea or snoring, and then others. They've been in a long surgery and they've had a lot of anesthesia. That can potentiate the effects of those opioids. Maybe they're used to opioids. They've been on long-term narcotics. It may take a little bit more to get them over that initial pain hump. Maybe they're on benzodiazepines or they have cardiac disease. Thoracic surgeries, you know, if you've had a chest tube in, it hurts, and coughing and deep breathing that we require them to do and making sure they're exchanging their air, it hurts when those things are in place. ISMP, they still talk about in the blue box, follow the standard sedation scale, use whichever one you want. These blue boxes spell out which ones from ISMP on monitoring. Pretty much everything's checked. All the boxes are checked. And even the Anesthesia Patient Safety Foundation, they talk about post-op opioid analgesics, how we can safely maintain these patients on them. They also added a recommendation from the Patient Safety Movement Foundation. And here they have said, okay, if you have patients on IV opioids and they're on supplemental oxygen, look at Entitle CO2, because it reacts faster. And if they're not on oxygen, Pulse Ox, continuous Pulse Ox. So one or the other. Now you may want to do Entitle CO2 for all of them who are getting the IV opioids. The other ones you have to think about is how are you going to react if they're starting to have over sedation? In other words, what's your monitoring system? How are you going to notify staff effectively? I hear that beeping, we kind of get alarm fatigue and don't hear the alarms anymore. Okay, what are your monitoring systems going to do to make sure that doesn't happen? And then what if that nurse is tied up and can't get to that patient? Who can go in after the fact? Is it going to be the charge nurse that's going to run in and see what's going on? So that just happens to be the Patient Safety Movement Foundation where they talked about it, which is our third, fourth question, Lindsey. Okay, let's get this one up here on your screen. Okay, you should now see this one that says, our hospital permits the following personnel to administer blood and blood products. And you can check all to apply to your organization here. Physician, MD, NDOs, nurse practitioners, midwives, physician assistants, registered nurses, licensed practical nurses, or possibly not sure who is or is not allowed. And it looks like we have one question that has come into the Q&A here, Laura, that says, do we have to have the standing order for ACLS in the medical record? No, no, no, no. Good question though, but no. Perfect. Hey, I don't see any other questions. I know that this was our last polling question. So if you have any questions, y'all go ahead and make sure you're tapping those into the Q&A so we can make sure to address those. Just a comment here in the chat that says, our facility does not carry blood products. Okay, and the criticals, you're not required to do that. You're not required to carry blood. Okay, we've gotten some good varying responses here. I'll go ahead and end and show that result. Okay, wow, we're all over the place. That's cool. Okay, so blood. Of course, we confirm the right patient and the right product. CMS, they call for two qualified people to do this confirmation, one who is actually administering it, one who's putting up the blood and watching them. Joint Commission, on the other hand, says, if you're doing barcoding, you're only required to have one person. Now, CMS says, okay, that's fine. The Blood Bank Association, that's fine. It's gotta be a policy, make sure that that hasn't changed. And that's okay. So if your Joint Commission deems status and you're using barcoding, then you only need one person. That's usually the person who's administering it, who is going to be doing that. So of course, you document what you did, how often, that's up to your policy and procedures, who's going to do the monitoring, and what do you do if they have a reaction? And one big question is, they have to be able to identify what is a blood transfusion reaction. Overall staff competent in venipuncture, because they have to know, okay, where does this go? And how big of a needle am I going to need? They have to be trained to detect and intervene, not only in blood, but also opioid over sedation. That's why we need to document that competency in their files. Make sure, by the way, your nursing education's aware of that, and that they know what the policy and procedures are. Surveyor will talk to staff. You're administering IV meds. What kind of meds are you giving? What is their, how would you know if this person's reacting to that medicine? How do you check them for it? Same with blood. And do they know, okay, what size needle are you using? How are you going to maintain any fluid electrolyte balance if you're really pumping them full of fluids? What about appropriate monitoring for those IV meds? And then how do you intervene and detect? They'll look for any blood transfusions. These are the folks that are going to look at their files for competency, because they're encouraged to watch staff hang blood or observe IV medication administration. Did they use safe practices? Did they wipe it off? Did they clean? Did they wear gloves? Whatever it happens to be. Was it a good IV access port in order to administer that blood? Do they watch the patient? Were they correctly identifying any patient who did get blood? And how did they report the reactions? So that's tag 1411. This partly goes into that just culture. So you have to have a way to report them, whether it's an adverse reaction or an actual blood transfusion reaction. And errors. I want to point out, there's also a tag in the pharmacy section that affects nursing, and it talks about reporting medication errors. A surveyor, they want to see and ask, how do you report errors? They may review them, other documentation that you put into your QAPI. They will ask to see incident reports. Now, if you have a concern on disclosure, please consult with your in-house counsel on that. Because usually when you get CMS in, one of the regulatory agencies, they want to see something, your counsel will probably say, yep, they get to see it. Have a way so that folks know when to report and what to report. And that's usually, again, your incident report. Transfusion reactions, if you've ever seen one, they're nasty. They can be life-threatening. So that's why we have to know how are they reacting. Are we getting bloody urine? Are we going into failure? It can be that extreme. Anything from itching to death. So that's why transfusion reactions really have to be taken seriously. Have a policy to ensure that they are reported. And immediately to the practitioner, we document in the chart and send those through QAPI. That's again, there may be a system that we need to look at to nail that down. And then finally, some home administered or self-administered medications. I combined them here because it's the same requirements and the same survey procedures. Your hospital can allow this. It's up to you if you want to do it. That's where the patient, their caregiver, whoever it is, self-administer. But your hospital has to make sure that there are policies and procedures on this. And by the way, this can include those that you provide to the patient or those they bring in. But define them in the policy and procedures. You have to have an order for this to occur. We have to assess the patient. Are they really competent to do this? We want to do kind of a see one, do one, make sure the patient's doing it correctly and safely. Then the other policy, how are you going to secure that medication when it's not being administered? Will it stay in the drawer? Will it be in a locked area? Will it stay at the nurse's station? And of course, documentation when it is administered. Again, you're not required to do it, just may be helpful, like with some of your inhalers, it may help to have those bedside. We just want to make sure that if you're doing it for observation patients, you may want to keep this in mind because Medicare doesn't pay for oral medications when they're an observation. Teaching a patient on their medications could help also avoid those readmissions. Make sure they're doing it right once they leave you. Maybe you want your nurses to supervise a couple times. Include in your policies when supervision is needed. Medications you don't want to include in self-administration because everybody needs to participate. Medical, nursing, pharmacy, they have to help in developing these policies. Surveyor will make sure that you're assessing the patient and that the standards and the policies are kept. Okay, critical access. You have very few tag numbers and again, much overlap with the acutes. Briefly, your deficiencies weren't as many, but these are only from 2018 going forward. So, nursing services was right up there again, but surprisingly your care plan was the least. So, services to meet the needs, RN has to provide or assign care according to what the patient needs and competency of your staff. As with an acute, you have to have a service that is well organized and someone who's responsible for the nursing services hospital-wide. They develop the policy and procedures. It is expected to be an RN and however you call them, that's up to you. This leadership, they are responsible for the management and evaluation of care. That means they're responsible to evaluate and review, develop and maintain policy and procedures. They also have to make sure there's supervision of the staff. Whether it's direct, they want to do it themselves or they use a manager. I've been in some of these criticals where the chief nursing officer is also the risk manager, but is also providing care on the floor. There has to be a review and analysis of care. Agency nurses, they also have to be oriented and supervised. But for here, you have to have an RN or LPN or clinical nurse specialist on duty whenever you have one or more inpatient. They have to make sure you have enough staffing, that you have enough supervisory, non-supervisory personnel. They're competent, educated, trained, oriented, licensed. When required, you may have certified nurses' aides. Staff have to be aware of the policies and how do you assign and coordinate care. Surveyor, they're going to talk to the RN. How did you assess the needs of the patient? How did you assign them? How did you make sure you're meeting the needs of these patients? How do you make sure your staff is trained? Are you sure they're oriented? How did you verify orientation? Like with an acute, they'll watch you provide nursing care. They want to make sure you have enough staff. They'll look at your schedules. And they will review personnel files. Again, they're looking for licensure. That's what they're looking for. They also will look at the assignments on at least one unit. Get the RN or director of nursing, whoever they happen to be, make that assignment. Is there enough supervision? And if you happen to have a temporary agency nurse, they will interview them. How familiar are you with what goes on in this hospital or unit? The RN, here they allow a PA to supervise nursing care for each patient. Usually in your acutes, you've got your RN. Here they do allow an RN or a PA if the state permits it. Otherwise, care according with the patient. Now, on outpatients, because what's critical is you're very so closely aligned with outpatient care. If you have outpatients, you don't have to do a care plan. Still have to follow acceptable standards of care, medication administration, everything. But if they're inpatient, yes, they need a nursing care plan. The surveyor will look at your staffing plans and want to make sure someone's evaluating care for the patient. And they'll talk to at least one of those RNs who supervises and evaluates. What did you look at? How did you determine that this person could properly do it? Drugs and IVs, they're administered under the supervision of an RN or a physician, or if your state allows, the PA. As with the acutes, you have to have an order signed, dated, and timed. They are written within the standards of care and consistent with any state and federal laws. They do have certain required policy and procedures and, of course, written administration of drugs and biologicals prepared in accordance with what your state laws say. And they do, again, mention all of these resources. You have to specify who can administer meds according to what they're allowed to administer. Have to have a signed order by someone who's authorized to do it. If you're going to accept verbal orders, policy on that. Standing orders, most use it. And what is the minimum content of those orders? And I listed those out before. So it's name, dose, route, frequency, et cetera. Make sure you're having compliance with those acceptable practices. What are the minimum contents? Policies for verbal orders. Self-administration, if you're going to allow it. IV medication administration. Documentation of your patient and also those who are receiving medications. How did you assess them? I have here on slide 184 what are the contents of an order. Very familiar. Exactly what's in Appendix A. And then for verbal orders, the regulation does require, does require, be written, but you are not precluded from using them. You can use verbal orders. You can use standing orders. But again, the practitioner has to authenticate them as soon as possible. And policy and procedures on both. And when I'm talking, again, standing orders, those when you have a patient who comes in through the emergency room, perhaps your cardiologist, whoever it is, happens to have those standing orders, they just have to sign off on them. And these are what's the requirements in your policy. This is the minimum. When verbal orders can be used or when they're prohibited, how you establish the identity of who's calling in that verbal order. What are the elements for that process? Communication back. Again, read back. Who can accept them? Who can act on them? And documentation into the medical record. Standing orders, you have to have a way that they're going to be together. How are they going to be approved, evaluated, updated when necessary? When can staff initiate? Under no circumstance, I don't care if you're critical or an acute, under no circumstances can a person who is not authorized by their scope of practice initiate a standing order. That is not permitted. They have to be within their scope of practice to initiate that standing order. And then who is going to authenticate them? Again, the blue box on verbal and standing orders, pretty much the same as what's in the acute section. Overall standing, that's your electronic orders, your order sets, and when you can initiate treatment without having to wait for the order. Now, you have to look at those situations where if you're going to initiate it and it's outside the scope of a non-practitioner, look at those situations where that can occur. Now, I want that predefined clinical use. Think your code blues, your rapid response team. Look at those annually and update them for any updates or corrections. Just have to look at them. If they're still good, okay, you've done your job. The minimum medication policies, it's the same as Appendix A, training, self-administration, timing. What can be ordered or eligible for timing and those that are not eligible? What do you do if it's a missed medication? How are you going to assess your patients, those who are receiving IV meds and blood transfusions? And again, tracing the lines, not forcing that connection. There's a reason that you can't connect it. Monitoring those who are getting IV meds, whether it's post-op patients getting IV opioids or blood administration, and of course, documentation. As with an acute, you have to have a current nursing care plan for each inpatient. It starts on admission and you have to keep it current. Keep it updated. What are the goals? What are their treatment preferences? What are the factors involved? And discharge planning. The care plan, they have to have appropriate interventions based upon what the patient needs. It must be a part of the permanent record. You can't take it out. It has to be a part of the record and part of that interdisciplinary plan of care. The surveyor will make sure there is a plan of care started soon after admission and that it's revised as necessary. So now I want to talk about sections within both manuals that are outside of nursing, outside of the nursing standards, but still impact nursing. We have a copy of their rights. So I'm admitted. Somebody has to give me a copy of my patient rights, including visitation. Review of contracted services. Now you think, why in the world think of your agency nurses? We still have to look at those contracts. Emergency services in the emergency department. Interpreters. Grievance. Informed consent. Advanced directives. These are in the patient rights section. Right to privacy. Freedom from abuse. Confidentiality. Restraint and seclusion. Then we have a switchover to performance improvement. History and physicals. Why would we look at that? Because nurses have to confirm there is a history and physical on the record before a patient goes to surgery. Medical records. What's the completion? Discharge summary and planning. Huge. Nurses are very highly involved with discharge planning. Pharmacy and medication. How do you get it down there? How do you get it back? Radiology orders. Do I have to give this patient something before they go to radiology or monitor after they have a radiological procedure? Lab services. Blood and blood components. Administration. Securing it. Dietary. How are we going to assess our patients? How much are they eating? What's their INO? Are they gaining weight? Are they losing weight? And utilization review. Other sections. Very broad. Infection prevention and control. Discharge planning. Nurses are heavily involved in both of those. We have organ donations because you have to notify the organ procurement organization if a patient's death is imminent or if they have died. Who is going to do that? Surgery and anesthesia. Taking care of patients. Verifying what's in place. Outpatient. Then rehab and respiratory. In short, pretty much in a majority of both of these appendixes, impact nursing in one form or another. So it brings us to our final one. I'm glad we have a little bit of time left over. So I'll go ahead and read through this. We have a patient who's admitted to the hospital. 180 beds. Acute abdominal pain. This thing is radiating retroperitoneal. Vitals are within normal. But the patient has postural hypotension once they stand up. Admitted for possible gastric ulcer. There's a little bit of history in the background. A lot of stress in his life. But no bloody emesis or tarry stools. His care is assigned to an LPM. Now this unit happens to have 16 beds with one RN. They're admitted to the floor. They're adjacent to ICU, which was full at the time. On admission, the physician calls in verbal orders. They want diagnostic testing, keep the IV TKO, get this person typed across for three units, hold blood. Because again, they weren't too sure, you know, is this abdominal pain gastric or is it something else? Some routine labs, pain medicine, and then strict bed rest. So we take these orders. The unit clerk takes the orders, verbally relates to the LPN, except for the bed rest restriction. So the patient says, I got to go to the bathroom. And they were assisted up by a nurse's aide. Now while in the bathroom, the patient collapsed codes and can't be resuscitated. And of course, post-mortem shows complete dissected aortic aneurysms. What concerns, if any, do you see with this particular nursing care? And I take it, Lindsay, you'll have that into the chat box. Great. So I'm going to flip just through a few of the appendix sources in here. They have notices for you, OCR does, on what needs to be in their form. I've tried to include as many of these resources that are free to you. So you don't have to pay for another one. There are one or two, I think maybe the infusion nurses, you might have to be a member. But like the NANALERT, IHI, all of these are free that you can access them and get what you need. And I've gone through and pulled up the most recent, like for ISMP, the high alert medications, or those that you need to be aware of, look-alike, sound-alike medications, because that still tends to be a problem with this. So we have about 15 or so minutes. Any questions, Lindsay? Yeah, there are just a couple here. Okay, let me scroll back up in the chat and make sure I'm reading the most recent one here. Okay, it says, are care plans required in the emergency department? No. No, if the patient's admitted, yes. Again, you can think of ER as kind of an outpatient. Now, if you get one patient who comes in and has to go to observation, and this is, you know, they do come in often, maybe a care plan would be beneficial, or they're coming in for observation for, say, wound care, whatever it happens to be, they're having a little bad effect from it, a care plan would be beneficial. You decide that on your own, but ER, no, you do not need to have a care plan unless they are admitted. All right, and there are a few comments here for the final discussion. Before I get to that, let's see. Okay, there's one other question here that says, in the outpatient observation status, do they need care plans 24-48 hour admission? Hmm, for observation? They say in the area, you may find it beneficial for this patient to have a care plan. You may. How extensive, that's up to you. Because, again, if they're coming in, or they've just got something you're not sure about, maybe a care plan would help them. Yeah, maybe it's one or two lines. Same with discharge planning. Maybe you want to institute discharge planning for that person. You're not required to do a care plan for observation, because that's not inpatient. Inpatients have to have that care plan. That's mandatory for them. Again, you may find it beneficial, because if they're going to be there for a while, the person taking over, once the staff member who assessed them is gone, could find it helpful. And short answer, no, you're not required. Okay, and it looks like just one final question has come in here that says, are there any recommendations on the ISMP newsletters that are paid services, and also who they are distributed to for review and action? If the facility does not subscribe, must they have an alternative means to become aware of med safety issues that are trending? Yeah, usually your pharmacist, they need to be like person number one, to be aware of the ISMP, as far as what's going on. And then hopefully pharmacy and medical staff are communicating on these issues that come up. Some of them will also do the NAN alert when there is an issue with a medication administration. We had a huge, or the MERC, NCC MERC, I think is what it was when we were doing a lot with our vaccines. There's also the VERS, the vaccine event reporting, that you can tap into. You don't have to be a member for those. So you may want to think about having your pharmacist designating one or two of the chart lead nurses to have access to that information, so they can be aware of, oh, this is what's going on. Okay, and then let's see, there are several responses here to the final discussions. This person says, orders taken by the unit clerk and not a nurse. Not all orders were relayed to the primary nurse. RN had not assessed the patient. High acuity assigned to LPN needs to meds to mask pain and cause, let's see. Very similar responses here. Orders taken by secretary and verbally given to nurses. So yeah, lots of similar responses here. Inappropriate assignment to LPN, et cetera. Excellent. Yeah, you've nailed it perfectly. Because, okay, first off, why was this patient who's got orthostatic hypotension and this kind of pain, I'm sorry, an aneurysm, one of the key areas and complaints is, I've got pain in my abdomen. It's radiating right to the back of my back. Big key. You're right. Never should have been assigned to the LPN. Unit clerk had no business taking those verbal orders like, hold on, doc, I'll get you a nurse. And if the physician had set up and said, no, no, I don't want to wait for a nurse. I'll just give it to you. No. That's when it says, I can't and hand it to the nurse. And you're right. LPN was not the right person to be taking care of this patient. A lot of lack of communication in this part. It was a really sad outcome because we think he could have survived the surgery had we gotten him taken care of quickly. And I understand when you have some men who have a little issue with a female standing there while they're going to the bathroom. I get it. But it does. We just have to explain I am here for your safety and well-being. And this is what it has to be. Period. I want to thank everyone. I want to thank you, Lindsay, for helping with all of this. Again, if they have questions, have them reach out to you and let me know and I'll respond. I'll respond back as soon as I can. So thank you, everyone. Perfect. Thank you so much, Laura. I did just post a final reminder there for you all in the chat. If you have not joined us for webinars in the past, we do have a process in place. If you are receiving an email the day following the live presentation and that email will actually come from education, no reply at zoom dot us. And so because it does come from that zoom email domain, it may get called in your spam or quarantine folders. And so if you don't see that email in your inbox in the morning, possibly just go ahead and check those additional folders. And then if you still don't see it, but you would like to go back and access the recording, you can always use the same zoom link that you're using to join us for today's live presentation to also access that recording. And then just remember that the recording is available for 60 days from today's date. And we do have an additional security measure in place of manually approving each of those recording access requests. So you will need to click on the zoom link, type in your information, and that will prompt an email to come to us for approval. We do typically approve those requests very quickly once validated, but we ask that you give us one business day to grant those approvals. And then also included in that email will be a link to the slides that were presented today. But I did go ahead and provide that link there for you in the chat I have as a resource now as well. And if you are joining us as a member of the Georgia Hospital Association, please also pay special attention in that email to the link to the survey that you may complete to obtain continuing education credit information. If you are joining us as a member of a partner state hospital association, please reach out to your contact at your hospital association to obtain any information regarding CEs that they may be providing for today's webinar. Okay, I don't see any other pending questions. As Laura just mentioned, you do see her contact information here on the screen, but please don't hesitate to reach out to us at education at gha.org. We'll be happy to get your questions over to her, and we are just so thankful for her providing very timely and thorough responses to your questions. I know she goes above and beyond in doing that for us. We greatly appreciate it. And we thank you all for joining us today, and I hope you found today's presentation to be valuable and the information to be helpful. And thank you, Laura, as always, for your time and information that you shared with us. We look forward to having you all back with us for future sessions. Hope you have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

Laura Dixon

healthcare compliance

state laws

federal laws

nursing practices

medication administration

qualified staff

clear policies

proper documentation

patient safety

regulatory compliance

ligature risk

discharge planning

non-discrimination policies