CMS Hospital Improvement FINAL Rules: Nursing, Medical Records, Infection Control, Antibiotic Stewardship Program, Restraints, QAPI, and more


July 21, 2020


Sue Dill Calloway

  1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

* Not able to attend the live session? We can arrange an on-demand session for You. Please call 1-951-801-2324


CMS has finalized some significant changes to the hospital conditions of participation (CoPs) that every hospital should know, including critical access hospitals. It was 393 pages long and combined three laws into one. This include changes to nursing, medical records, infection control, QAPI, patient rights, H&Ps, and restraint and seclusion. 

Most have an effective date of November 29, 2019 with two exceptions. The normal implementation date is 60 days but Critical Access Hospitals will have 6 months to implement an antibiotic stewardship program and 18 months to implement a QAPI program since their QAPI requirements were completely written.

It will also require all hospitals to have an antibiotic stewardship program and what the program should include. Also a great part of this document included things that CMS has found to be problematic in hospitals that are already a requirement in the hospital CoPs. CMS also clarified a number of existing requirements and a number of federal regulations that are already final which makes this webinar an excellent resource.

Session Highlights:

  • Recall that hospitals have requirements in the CMS CoPs on  antimicrobial stewardship program
  • Discuss that CMS change  the term LIP (licensed independent practitioner) to LP (licensed practitioner) so PAs can order restraint and seclusion and do assessments if allowed by the hospital
  • Describe that the hospital must have policies that describe which outpatient areas require a RN
  • Recall CMS removed the section that required hospitals to conduct autopsies in cases of unusual deaths

Who Should Attend?

  • Pharmacist
  • Chief Nursing Officer and Nurses
  • health information management
  • Infection Preventionist
  • Antimicrobial Stewardship Team Members
  • Chief medical officer
  • QAPI Director and Staff
  • Patient Safety Officers
  • Regulatory and Compliance Officers
  • Physician Assistants (PAs)
  • Hospital Legal Counsel